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MIE8299 - SECTION VI - PLANNING FOR THE FUTURE

Section VI- Planning for the Future

 

The fourth and final of our process of Motivational Interviewing is planning. In the planning process, the clinician hopes to help reinforce commitment to the change a client has identified and develop a specific plan to get there. The planning process and the focus on developing a goal with objectives and interventions is not unique to Motivational Interviewing, however the focus on consideration of obstacles and reinforcing the commitment to change throughout the process of planning might be new ideas for those learning Motivational Interviewing.

As the clinician begins to feel that the client has effectively resolved their ambivalence and it seems as though they are committed to take this step forward, the clinician wants to consider that it might be time to develop an action plan. There are several indicators for a clinician to monitor that serve as warning signs, that the client is ready to move from Evoking to Planning.  One of those indicators is when the client demonstrates an overall increase in change talk.

As the clinician, this shift may occur when you are hearing a lot of DARN CATS language, particularly the CATS, or mobilizing language. In considering the Transtheoretical Model of Stages of Change again and the way in which it weaves its way through the motivational interviewing approach, we might be thinking of this process from Evoking to Planning as similar to the shift between the Preparation and Action stages of change. 

It is important for the clinician to tune his/her ears to commitment, activation, and taking steps.  Perhaps the client who has been considering going back to the gym told you that in the week leading up to the session, they purchased some running shoes, or they’ve started to make some plans or adjustments with their family to arrange for child care as they prepare to get back into the gym.

In addition to hearing more change talk, particularly mobilizing language, as a client shifts from the evoking to planning processes the clinician will also hear less sustain talk. The client will be speaking less about the reasons to maintain the status quo, such as not going back to the gym as indicated in the previous example.  The language we hear from clients in this stage largely favors making a change, and all indications are that the client is effectively resolving their ambivalence.

Despite the emphasis on resolution of ambivalence, it can be misleading when we think of ambivalence as resolved or unresolved, especially if we consider the framework of the Transtheoretical Stages of Change model.  When thinking about change from this model, we certainly do not view change as a predictable and linear process. 

It is important to note that there may be some ambivalence that re-emerges for the client in the planning process.   It is important to remain guiding, not directive, in our style as the clinician during the planning process. Remain attuned to ambivalence during this transition period, but also do not slow the client’s process of moving into planning just for the sake of ‘getting more change talk’. 

If I hear a client telling me things like “I know that maintaining my current behavior is just not an option.”, “This has to be the time to make this change. The stakes are awfully high and I don’t think I have much time left”, I can begin to test the waters and move towards the planning process with the client. 

There are a few other things we want to listen for during this evoking-planning process.  Projecting and imagining a future with lives that include these changes is a strong indicator that we can begin to move forward into planning.  We will hear the client start to think about what their life might look like once this change has taken place.  Maybe they will start to talk about being excited for an upcoming 5k race several months down the road. This will give you the impression that they’re not only thinking about making this change in the present, but they’re really thinking about the future and how their lifestyle may be different once they’ve made some of these changes. They may also imagine some of the other things that might take place as a result of this change. So, maybe they’ll start to talk about ways in which the family will be closer if they stop smoking cigarettes, as their will be less tension in the home.  It becomes evident to the clinician that this client is really spending a significant amount of time thinking about how life will be different once this change has taken place.

One final indicator that a client might be ready to transition from evoking to planning is that they are asking questions about change. The client will start to ask questions such as, “What should I expect?, What’s a realistic time-frame for me to stop experiencing cravings for smoking cigarettes?”, What is a reasonable way to get back into the gym where I don’t feel sore and otherwise less motivated to go back because of some of the physical strain that put on my body because I over did it the first day?”. 

When the client is asking questions about this change, they are often projecting or imagining some of the logistical concerns they might be faced with as they move forward.  Some of these logistical concerns might be based on lack of experience with this particular change, or may be based on previous insights gathered from obstacles they faced when making this change or a similar one in the past.

A ‘key question is a specific way in which the clinician hopes to assist the client in transitioning from evoking to planning.  The ‘key question’ can be thought of as the mechanism that bridges the two processes. A ‘key question’ is often a simple question that helps to test our hypothesis, that the client is prepared to move into developing an actionable plan for change. 

Examples of key questions are “Where does this leave you?, What do you think your next steps will be?, What do you think will be the first thing that we need to plan for as you move forward into this change?” Asking this kind of question takes the idea of change from hypothetical to something more tangible.  If we are to think about those stages of change again, the ‘key question’ can really be considered as the way in which we bridge between the preparation and action stages of change.

Prior to using a ‘key question’, the clinician should take the opportunity to summarize the change talk they’ve heard up until this point.  The client may have spent two or three sessions with the clinician at this point, and thoroughly explored their desire, ability, reasons, and need to make this change.  The clinician working with Mr. B might summarize change talk this way…

Clinician: “Over the past few sessions we’ve really talked about a lot of the reasons in which you think this change makes sense for you. You’ve talked about some of the health consequences that you’re experiencing and also started to think about how some of those health consequences may even become more significant if you don’t make a change to smoking. You’ve also talked about how your family feels very strongly about you making this change because they love and care about your well-being.  You have told me about how important your family is to you.  You’ve talked about how you think if you were to make this change it may result in some reduced tension in the house and ultimately some more positive interactions with the family. We’ve also talked about how you’ve spent a lot of money as a result of smoking and how the cost of smoking continues to rise and how it’s become a significant portion of your budget. And while, it hasn’t created catastrophic financial consequences for you at this point, you can certainly imagine how you would have more freedom financially if you were to make this change. Is there anything I might have missed?”

In summarizing this change talk, what the clinician has done is reinforced a lot of the change talk language and helped to set the stage to follow up with a key question.   

Mr. B- “Yeah, I think that about sums it up. It’s interesting to hear all of that combined together like that.”

Clinician- “With all of that information and all that we’ve talked about, where do you think this leaves you? What do you think you would like to do next?” (Key Question)

Mr. B- “I mean after hearing all of that, it really seems like there is only one thing left to do and that is stop smoking.  I have the appointment scheduled with the Nurse Practitioner next week to talk about medication options.  I will be going to my first group (smoking cessation) this week, so I think it’s just a matter of doing it at this point.”

Some of the final areas of consideration as the clinician assists the client in transitioning from evoking to planning is the clinician’s level of comfort with ‘testing the water’ and silence.  As the clinician suspects that the client might be ready to move into the planning process, they may also worry that they are moving too quickly, or misinterpreting the client’s level of readiness.  Testing the water allows the clinician to test the hypothesis, that the client is ready to move into planning.  As the clinician decides that it is an appropriate time to take that leap in testing their hypothesis, they might utilize a key question.

Clinician- “It sounds like you are thinking about taking some action.  What do you think is the first step you will make in working towards this change?

When testing the water, be prepared for the client to express some apprehension and state things like “I still don’t know that I’m fully ready.”  The clinician has gained valuable information here, indicating that the client is not yet ready to move into the planning process and instead the clinician’s focus will be to further resolve ambivalence and evoke change talk.

Oftentimes clinicians will ask me, “What if the client seems overambitious and their desire to move into the planning process seems disingenuous or unrealistic?”  If, as the clinician, you have this concern and believe that the client is not being entirely realistic about some of the challenges associated with this behavior change, and you get the sense that this person is giving a false sense of confidence with regards to the change, I would suggest that the clinician utilize the elicit/provide/elicit style of exchanging information to express their concerns.  However, if many of the indications discussed above are present, and client says they are ready to move forward, often it is best for the clinician to join them in this planning process. 

The clinician also wants to be mindful of the use of silence during this particular process.  This may be the first time the client has actually thought about what the logistics associated with this change are, what the specific steps are that need to be taken in order to make this change and it might be a bit frightening.  The clinician should allow the client to sit with the silence for a moment to explore the, sometimes intense feelings they might be having about making those changes.

Now that it is time to move forward with the client and we are firmly in the planning process of motivational interviewing, the clinician should be prepared for several planning scenarios to emerge.  The first of the planning scenarios is when the change plan is clear. The clinician’s role might be limited to summarizing the plan by focusing on some of the previous mobilizing language. In addition to summarizing the plan, the clinician will also help to troubleshoot.

In troubleshooting, the client and clinician collaborative consider some of the obstacles that might occur and beginning to come up with some type of contingency plans for those challenges. After summarizing the plan, and troubleshooting, the clinician will help the client to increase specificity related to the plan.  The client will be challenged to nail down specific times, frequency, places the objectives will be met.

The second of the three planning scenarios is when there are several clear options for change. The path is not entirely clear. It is clear that the client wants to make a change, but there are a number of different available options for treatment, or intervention.  Each of these options may be helpful for different reasons.  The clinician wants to first go back and clarify with the client what exactly the goal is.  Let’s imagine Sierra’s case again.

 

Case Example # 3

Sierra- “I only ever started smoking marijuana after a recent automobile accident. I’ve been extremely anxious, I’ve been on edge, I felt as though the only way that I can get an effective sleep at night and be ready for school the next day is if I smoke some marijuana before bed time.  I understand that you guys are focused on the marijuana use and everybody wants me to stop using marijuana, I don’t know that I’ll be able to unless I deal with these feelings from the accident.”

When there are several clear options for intervention or planning, the clinician wants to explore what the client’s hunches are about different approaches.  the client starts to give us some of their hunches about different approaches.

Clinician- “You feel like the solution is not as clear as stopping use of marijuana.  It’s important to also address the anxiety and trauma.”

Sierra- “I’m willing to make some changes, I’m willing to do things different. I am scared about my marijuana use and its spiraling out of control and leading to more issues. And, I don’t know that it’s going to be all that helpful unless we deal with the anxiety about the accident.”

At this point we have several clear options.  In option one we could treat the marijuana use first, despite the client’s hunches.  In option two we could make a recommendation for this client to proceed in some type of trauma-specific treatment, despite our clinical knowledge that use of illicit substances is contraindicated while receiving exposure-based therapy.  Instead the clinician in this scenario, chooses to utilize the E-P-E model and collaboratively works with the client to consider other creative solutions.

Clinician- “What do you know about the relationship between marijuana use and trauma or traumatic events?”

Sierra- “I don’t know all that much about it. I’ve learned that, obviously, since I’ve been dealing with all of this anxiety which seems to be related to the accident, the only relief I’ve got is from smoking marijuana. So I can certainly see why people may smoke who’ve had a history of trauma.”

Clinician- “Yeah, would it be okay if I shared some information about the relationship and what I’ve come to learn from working with other clients?”

Sierra- “I guess so.”

Now the clinician will provide the client with some information about the correlation between substance use and trauma. The clinician may also talk about treatment related concerns, such as

Clinician- “Many trauma-specific treatment programs require the client to be free from any intoxicating substances during the time of their treatment in order for the treatment program to be most effective.  What are your thoughts about that?”

Sierra- “Well yeah I get it. I guess I cannot really do trauma treatment and exposure if I’m not fully there; I’m not fully able to experience my emotions, so I guess that makes sense.  While that make sense, I still feel stuck. You know I’m willing to deal with the substance use if that’s what is being asked of me, but the reality is I’m still going to go home every night and still have that temptation to smoke. And with how terrible it feels - the anxiety and those memories, and all of the things I experience - I’m worried that I won’t be able to resist the temptation to smoke marijuana, even in an outpatient program.”

Clinician- “You are really committed to making this change and an outpatient program does not seem to be an option that will set you up for success.”

Sierra- “Yeah, if there was a program where I could get away and just deal with both things at once…I think that would be best.  Every way I think about changing one of the problems without the other just does not seem to make sense.”

Clinician- “In order to accomplish this goal, you feel like a residential treatment that focuses on treating both mental health and substance use is necessary.”

Through this collaborative discussion and troubleshooting, the clinician has helped the client too develop a really clear perspective on what is going to be most effective.  This plan is based both on your clinical expertise and the client’s hunches about themselves.

The third scenario for change planning is when the clinician and client are entering into uncharted waters.  The client knows that they want to make a change, but there are no clear or obvious precedents for making this change.  Perhaps the client has some unique challenges with child care or work schedule. This scenario requires the client and clinician to be creative in developing a plan. The clinician and client will focus on generating possible solutions, options, steps, or plans.  The clinician and client will both be best served to approach this process with an open-mind.

 

Case Example # 4

Clinician- “What are some of the ways in which you might be able to receive some type of treatment while not interrupting your current work schedule and taking into consideration your child care needs?"

As in the second scenario, the client and clinician will begin by clarifying the goal, exploring the client’s hunches about potential solutions, options, steps, or plans.  

Mr. Diamond- “Well I know that if I don’t do something I will probably just keep using and even though I’m doing my best to maintain my job it eventually won’t work out that way based on my history. So, I know I need to do something. I know I need to be involved in some type of treatment. And while work is important, I also know that work probably won’t be available to me if I continue down this path.”

The client and clinician might explore options such as early-morning or weekend self-help groups, contacting the employer and talking with them about accessing treatment through their EAP program, or utilization of FMLA benefits. Whatever the options are, the client and clinician are utilizing a collaborative mindset. 

As the clinician, we may have some experience in navigating systems such as FMLA or EAPs.  This, in combination with the client’s hunches about different approaches based on their expertise on themselves, will always underlie the whole approach of Motivational Interviewing.   The clinician is advised to be cautious in the planning phase and not to lose sight of the collaborative spirit of Motivational Interviewing. 

Next, we want to pre-emptively troubleshoot with the client by asking, what would be an indication that this particular plan is not working?  How will we know that it’s time to go to plan B?  This may require some future sessions or contact with the client in order to check on their progress.  Motivational Interviewing is a short term, brief intervention that oftentimes lasts no more than 2-4 sessions with a particular focus on a target behavior.

You may use Motivational Interviewing with an established client, who you are otherwise providing some type of treatment such as CBT for Depression or trauma therapy.  In those instances, it might be much easier to check in with a client’s progress towards goals and flexibly make adjustments to the goals as necessary.

One of the things that I often say to trainees, admittedly partly to be provocative, is that change really is not that hard. Imagine for a moment some of the responses that I receive to a statement like that.  Short of throwing fresh fruit and vegetables at me, trainees will often challenge me and say things such as “What are you talking about? Change is hard. Otherwise why would we be doing this motivational interviewing? Why would we be doing all of this work on helping to motivate folks? What do you mean change is not hard?”. 

This is generally where I chime in and help to clarify what I meant by challenging the participants to take a drive past your local gym in your neighborhood on January 1st.  If your hometown is anything like mine, you are going to drive past that gym and see a full parking lot.  The reason it’s full is because people are firmly supplanted in the Action Phase of the Transtheoretical Stages of Change Model.   

Similarly, there are probably thousands of unopened boxes of home exercise equipment that were ordered with the best of intentions. There are home libraries across the country with copies of Atkin’s Diet Cookbooks.  I think this speaks to the idea that, generally, taking action and initiating some type of change is easy when compared to maintaining change. It is important to keep that in mind as we utilize Motivational Interviewing and otherwise work with clients who are making significant behavioral changes - and really keep that perspective front and center while we’re thinking of folks in the planning phase. 

The importance of a clinician’s flexibility during the planning process of Motivational Interviewing cannot be overstated. In fact, this is probably one of the most important points that I’ve seen in my work in doing MI. It is important to recognize that just because somebody hasn’t followed through with or hasn’t been able to accomplish some of the goals that they had set out for themselves, this does not necessarily mean that they are no longer committed to change. It does not necessarily mean that they have not effectively engaged in treatment or that this change is no longer important to them. 

These assumptions can be a huge mistake for clinicians to make; that since somebody has not made this change or has not followed through that it is not important. Both things can be true.  Ambivalence remains a constant throughout the process and shows back up throughout this non-linear Transtheoretical Stages of Change model. While we might like for this to be a nice, neat, and predictable process, where the client has worked through this linear process and arrived at this transformation, it usually is not.  Instead the clinician is challenged to frequently revisit a client’s readiness to change throughout the clinical interaction.

 

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