D5- Case Study Addiction Assessment
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CHAPTER 9
Focusing A Deeper Dive
I am always more interested in what I am about to do than in what I have already done.
—Rachel Carson
Our plans miscarry because they have no aim. When a man does not know what harbor he is making for, no wind is the right wind.
—Lucius Annaeus Seneca
In Chapter 5, we introduced the focusing task of negotiating shared change goals. Agreeing on goals can often be a fairly straightforward process.
When people enter a weight-loss program, whether in person or online, they presumably hope to lose weight, and this goal will be consistent with the intentions of program staff. If a person’s goals fit within the helper’s competence and scope of practice, there can be relatively quick conver- gence on a focus for working together. In helping professions, it is typically clients themselves who determine the goals for change. In health care in particular, the process of shared decision making actively engages patients in choices regarding their own health.1
Goals can also change. Priorities may shift with a new crisis, diagno- sis, or life change, and even during a conversation itself. Focusing is not always a one-and-done event and can be an evolving process over time that requires refocusing. A guide’s role includes keeping a keen eye on destina- tions.
The focusing dialogue begun in Chapter 5 was between a schoolteacher and a fitness coach at a local gym. The conversation focused on the what and why of change, and in that discussion they arrived at two initial goals:
Miller, W. R., & Rollnick, S. (2023). Motivational interviewing : Helping people change and grow. Guilford Publications. Created from liberty on 2026-02-09 04:52:17.
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cardiovascular fitness and core strength. Now the narrowing-down process of focusing continues as they plan the how of change. It might be tempting for the coach to prescribe a fitness regimen that focuses the person on par- ticular exercises, but instead they pursue a shared decision- making process.
COACH: There are actually quite a few different ways to accomplish your two goals of better cardiovascular fitness and core strength. What I’d like to do now is help you choose what you want to do. First of all, I wonder what ideas you have already been considering.
Emphasizing choice
Asking for her own ideas first
TEACHER: Well, as I said, I used to be a lot more active. I ran, played golf, and went dancing when I was single, but I haven’t been doing any of those things.
COACH: So one thing you might do is pick up some things you used to enjoy doing. Of the ones you mentioned, which might be most possible for you to do again?
Reflecting
Asking
TEACHER: I might have time for a round of golf on the weekend, but I’m not sure how much exercise that gives me. Maybe I could fit in a run here and there to get back in shape.
COACH: How good are you at doing things on your own, like going for a run or maybe doing some exercise at home?
Asking
TEACHER: Not great. I tend to put it off. I used to run with a friend, and that got me up and out in the morning.
COACH: So having some structure or people to exercise with can help.
Reflecting
TEACHER: Yes, I think so.
COACH: I’m thinking about what we can offer here that might work for you. Is it all right if I tell you about a few options? Asking permission
TEACHER: Sure. That’s why I came in.
COACH: OK, good. You can tell me what might suit you best. We have different kinds of regular classes here where you could be
Offering choices
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Focusing: a deeper dive 157
exercising with other people. For example, I remember you said that you used to enjoy dancing, and there are two dance aerobic classes that are great for building up cardio fitness. You could also work with an individual fitness coach—there are three of us here. I can also show you the different machines we have that can be good for both cardio and core strength, and we have a pool for swimming. Which of those sound like they might fit your needs? Asking
TEACHER: I have never been much of a swimmer, though I hear it’s good exercise. I could look at the list of classes you offer and see what might fit my schedule.
COACH: I’ll get you the schedule. What else? Asking TEACHER: I have never used a gym like this,
but I guess I’d like to look at what you have available.
COACH: Certainly. We can do that now—we’ll just have a walk around, and I can show you what each machine in the circuit does. They are all adjustable to your own level, and you can gradually work up as you get stronger. Shall we do that?
Offering choice
TEACHER: OK. I don’t know if I’ll like using machines, but we can look.
COACH: You can pick and choose the machines you want to use for cardio or core, and any machine you don’t like is out. I want you to have a routine that you enjoy so you’ll stick with it.
Emphasizing choice
TEACHER: That sounds good.
Beginning from the client’s broad general hope, the coach (in Chapter 5) first worked with the teacher to narrow the focus to more specific objectives— increased cardiovascular fitness and core strength. Now, in this next conversation, they are narrowing further to specific exercises that the teacher is likely to sus- tain. In this segment, you can see a good mix of asking questions, reflecting,
The what, why, and how can all
flow from focusing.
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and offering some information. It also illustrates that the what, why, and how can all flow from a focusing task. Focusing is collaborative, blending the interviewer’s expertise with the client’s.
Navigating Differing Goals
What if the person’s goals do not converge with those of the helper, pro- gram, or setting? This can occur for various reasons. One possibility is that the person has knocked on the wrong door and needs to be directed to a more appropriate source of help. Perhaps the person’s request lies outside the helper’s zone of comfort or competence. Sometimes the helper or service setting offers help toward a limited range of objectives that do not encom- pass the aims of a particular individual or family. In such situations, an appropriate professional response would be referral.
Then there are situations where people seem to have come through an appropriate door but are reluctant to be there. This was actually the norm when we worked in addiction treatment settings. Most people coming in the door were not quite ready to change their use of alcohol, tobacco, or other drugs. Many were not even clear that they needed to make a change. For the most part, they were ambivalent. Part of them knew that all was not well, and another part was unenthusiastic or resentful about the prospect of changing. Often they had been pressured through the door by concerned family, professionals, or courts.
Thus we frequently found ourselves in the role of advocating for change with people who were hesitant about or even averse to it. It’s actu- ally a common scenario in many helping relationships: You want this and I’m hoping for that. It happens, for example, in advising people who have been spending beyond their means and are in debt, and patients with a new diagnosis who need to make significant changes in lifestyle. Those arrested for driving under the influence of alcohol may have little interest in changing their drinking (and driving), although that is the hope of their probation officer and family. Teachers aspire for their students to study and learn, and health care providers aim to diminish illness and suffering with or without much collaboration from those they serve. Not all people experiencing homelessness want to move right into housing. A specialist treatment program seeks to address particular problems, but some of the people they serve may be pressed into treatment by the family or court and have little desire to alter established habits. It turns out that ambivalence is common, even the norm, when people are considering a significant change in their own behavior or lifestyle.2
How do you negotiate the focusing task as a helper when you have hopes or goals for change that the person does not (yet) share? A good start is to keep the person’s own best interests at the center.3 MI is not about
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Focusing: a deeper dive 159
persuading people to do what you want them to do or what would be in the best interest of the setting in which you work.4 Persuading—trying to get someone to do something through reasoning or argument—is virtually the opposite of MI. Within a working alliance, a goal is not a goal until it is shared. It may be your hope (or that of the context where you work) for the people you serve to change in a particular way. You can certainly be forth- coming about your own aspirations, but they cannot be imposed. Some- times reaching agreement is easy: the person comes to you asking for help
toward achieving a goal that you can support. Other times you encounter the situation of differing aspi- rations, which is in fact where MI was born.
MI is a particular way of exploring whether a person can embrace a change goal. If the change is
not in the person’s own interest, if truly no part of them wants it, then there is no current motivation there to evoke. We found, however, that by the time people came through the door of a treatment program, even when they were pushed through, it was rare for them to perceive no reasons for change. By the time you meet your clients, they usually will have some inkling of a need for a change, even if they tend to sound as though they are unmotivated when others try to persuade them. If attempts to convince them persist, then whatever motivation they do have can be undermined.
When the client’s goals differ from yours, one question to explore is what they are willing to do. As we stated earlier, no one is truly unmoti- vated; everyone has wants and needs. A provisional plan can be to continue exploring a person’s motivations for change, and many options for such an exploration are available. In the course of everyday conversation, you may unearth some motivation and try to evoke and strengthen it, or you may explore what they do value and care about. You can seek to plant some seeds (Chapter 13) or choose to remain neutral on a particular topic while you continue listening and exploring (discussed later in this chapter).
The focusing task is about developing shared goals toward which to move. Responding according to the fixing reflex— seeking to persuade a reluctant person—is often counterproductive. It is something skillful coaches and salespeople know. Sometimes change goals are related to larger considerations:
• Decreasing sugar, salt, or alcohol consumption to preserve health • Taking practice tests to learn material or pass an exam • Refraining from illegal behavior as a condition of probation • Exercising to increase fitness in preparation for a physical challenge
Remember that it’s not a goal until it is shared and until the person accepts it. MI is a way to evoke people’s own motivations for why and how to make a change.
A goal is not a goal until it is shared.
Miller, W. R., & Rollnick, S. (2023). Motivational interviewing : Helping people change and grow. Guilford Publications. Created from liberty on 2026-02-09 04:52:17.
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As illustrated in the coach example above, discussion of the why and how of change can overlap. What is the person willing to do? What could be a step in the desired direction? It can be a narrowing down process that begins with broader goals such as being healthy, staying out of prison, or having a strong and loving relationship. What would be some possible steps toward achieving that broader goal, and of these, what might be a first step that the person is willing to try?
Exploring Values and Goals
Everyone is motivated. At times, the motivation is as immediate as finding the next meal or getting some sleep. When basic physical needs are satis- fied, people can pursue higher goals and values.5
A key in appreciating someone’s internal frame of reference is to under- stand their core goals and values. When you understand what people value, you have a key to what motivates them. What are their longer-term goals? How do they hope their life will be different a year from now or in 5 years or even in 10 years? Exploring potential life goals has a way of broadening your perspective and theirs, lifting all eyes to the far horizon.
It is a common human experience for day-to-day behavior to fall short of or even contradict longer-term life values. Such value– behavior dis- crepancies can come into focus through reflecting on larger life values, and perceiving such discrepancy can exert a powerful effect on behavior.6 Understanding values can be useful in the tasks of focusing (What is most important?) and in evoking the why (What motivations does this person have for change?) and the how of change (What paths toward change would be most compatible with this person’s values?).
In any such exploration of values, it is important to convey acceptance and respect. Doing so does not mean that you concur with or approve of the values being expressed; it only means that you accept that these are their stated values as you seek to understand what is important to them.
An Open-Ended Values Interview
One way to learn about a person’s values and priorities is simply to ask about them. Here are a few examples of open questions of varying com- plexity:
• “Tell me what you care most about in life. What matters most to you?”
• “How do you hope your life will be different a few years from now?” • “What would you say are the rules you live by? What do you try to
live up to?”
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Focusing: a deeper dive 161
• “Suppose I asked you to describe the goals that guide your life, the values you try to live by. What would you say are your five most important values, giving perhaps just one word for each. What would they be?”
• “If you were to write a ‘mission statement’ for your life, describing your goals or purpose in life, what would you write?”
• “If I were to ask your closest friends to tell me what you live for, what matters most to you, what do you think they would say?”
Obviously, the language used in such open questions should fit the person’s level of mental complexity. The purpose of these questions is to inquire about what larger goals or values people have internalized as guid- ing principles for their lives.
Having posed an open question, follow up with quality reflections. When people describe their values using an adjective (“faithful”), noun (“provider”), or verb (“to care”), what do they mean by it? Rather than just asking, make a guess in the form of a reflection.
CLIENT: Well, one thing I want to be is kind.
INTERVIEWER: To care for other people. [Reflection, continuing the para- graph]
CLIENT: I don’t mean just having warm feelings. I mean being a loving person.
INTERVIEWER: To love in a way that makes a difference. [Reflection]
CLIENT: Yes. I want to make a difference.
INTERVIEWER: For the people you care for, who are close to you. [Continu- ing the paragraph]
CLIENT: Not just for them, although I certainly try to be loving to my fam- ily and friends, too.
INTERVIEWER: But you mean something beyond your circle of friends. [Reflection]
CLIENT: Yes, to be kind to people I don’t even know; the check-out clerk at the market, children, a beggar in the street.
INTERVIEWER: You want to be kind to them, too, to strangers. [Reflection]
CLIENT: Yes.
You can also intersperse open questions to help the person elaborate, exploring more about a value.
• “How do you express [value] in your life?” • “In what ways is [value] important to you?”
Miller, W. R., & Rollnick, S. (2023). Motivational interviewing : Helping people change and grow. Guilford Publications. Created from liberty on 2026-02-09 04:52:17.
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• “Give me some examples of how you might be [value].” • “Why is [value] important to you? How did this come to be a value
for you?”
Be conscientious about following up with reflections instead of just asking questions.
INTERVIEWER: So why is it important for you to be kind, even to people you don’t know? How did that get to be a value for you? [Open question]
CLIENT: I’ve been so fortunate myself. I mean, I’ve had people who have really reached out to me and loved me and made a difference at crucial times in my life. It’s so important to do that. Sometimes you don’t even know how important what you did was.
INTERVIEWER: It’s like passing on what others have given to you. [Reflec- tion]
CLIENT: “Pay it forward” some people say rather than paying it back. Make a deposit—add a little kindness to the world without expecting any- thing back.
INTERVIEWER: That’s really important to you— something you want to do with your life. [Reflection]
CLIENT: Yes. There’s so much unkindness. That’s all you see in the news. INTERVIEWER: Inhumanity. [Reflection] CLIENT: Right. But there’s a lot of kindness in the world, too, and that’s
what I want to add to. INTERVIEWER: Give me some examples of times when you have done that . . .
[Open question]
Exploring what people care about— identifying, then asking more about, then reflecting and exploring values—can help in the engaging task as well. It strengthens relationships, yielding a deeper understanding of people and their motivations. A further benefit is that helping people voice their own values can serve as a kind of self- affirmation, which can diminish defen- siveness and facilitate change.7 To be heard deeply on what matters most can be a particularly powerful experience.
Structured Values Exploration
There are also more structured approaches for exploring values.8 A com- mon method for doing so involves a list or set of cards describing values that
Allow the person to voice their own values.
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Focusing: a deeper dive 163
could guide one’s life and behavior. Box 9.1 offers one such list of 100 items that can be used in values exploration, or you can develop your own list that is appropriate in your setting. A downloadable version sized for print- able business cards is available at www.guilford.com/miller2- materials. You can invite people to identify values in the list that are particularly important to them. Then you can discuss these core values to understand what they mean to that person. This can be done through a combination of open questions and reflective listening.
INTERVIEWER: I see that one of the top values you chose is to “Protect.” How is that important to you? [Open question]
PERSON: It’s my job to protect my family, to provide for them.
INTERVIEWER: So it’s a combination of protecting them and providing for them. [Reflection]
PERSON: Yes. I think that’s what a parent should do.
INTERVIEWER: And it’s one of the most important things in your life. What are some ways in which you protect your family? [Reflection and open question]
PERSON: Well, I bring home a paycheck to put food on the table.
INTERVIEWER: That’s something you feel good about. [Reflection]
PERSON: Yeah. I haven’t always been so reliable if you know what I mean. I’m getting my life together and want my family to be able to count on me.
INTERVIEWER: So you provide for your family by bringing home a paycheck. How else do you protect them? [Reflection and open question]
PERSON: I make sure they’re safe at home. Smoke alarms, good solid doors, and things like that.
INTERVIEWER: So they can be safe even when you’re not there. [Reflection]
PERSON: Right. I can’t always be there, but I want them to feel safe, to know that I’m there for them.
INTERVIEWER: You have a really strong sense of family. Why is that so important for you? [Affirmation and open question]
PERSON: Well, I didn’t feel very safe when I was growing up, and I was pretty lonely. I was an only child, and sometimes I had to protect my mom.
INTERVIEWER: And now that you’re a parent, you want your own children to know they’re protected, and to stick together as a family. [Reflec- tion]
PERSON: If you have strong family, you have everything.
Miller, W. R., & Rollnick, S. (2023). Motivational interviewing : Helping people change and grow. Guilford Publications. Created from liberty on 2026-02-09 04:52:17.
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164 a dEEPEr diVE inTo Mi
B OX 9.1. A Values Card Sort William R. Miller, Janet C’de Baca, Daniel B. Matthews, and Paula L. Wilbourne
These values are usually printed onto individual cards that people can sort into three to five piles. We have five header cards that read: “Most Important,” “Very Important,” “Important,” “Somewhat Important,” and “Not Important.” It is wise to provide a few empty cards so people can add values of their own. These items are in the public domain and may be copied, adapted, or used without further permission. A downloadable ver- sion sized for printable business cards is available at www.guilford.com/ miller2-materials.
Sample instructions for sorting the cards:
These cards each contain words describing values that are important to some people. Sort them into these five different piles depending on how important each one is to you. Some may not be important to you at all, and you would put those in the “Not Important” pile. Others that are just “Somewhat Important” go into this second pile. Those that are “Important” go here in the middle, and this fourth pile is for those that are “Very Important.” Finally, this pile is only for those values that are the “Most Important” to you. Go ahead and sort them now into these different piles based on how important each one is to you. When you’re done, if there are any other values that are important to you that are not mentioned on these cards, you can use these blank cards to add them. Any questions?
The starting order of the cards does not matter— simply shuffle them before beginning (except for blank cards). It is also possible to use fewer than five piles for sorting, such as “Not Important,” “Important,” and “Most Impor- tant.”
A possible next step is to have the person pick out the 5 or 10 values that are most important and rank-order them from 1 (most important) to 5 or 10. There may already be this many cards or more in the “Most Important” pile, or it may be necessary to add some from the “Very Important” pile. Alternatively, it is possible to skip the first (sorting) step and just have peo- ple pick out and rank-order the 10 that seem most important. This could be done just from the list below, but having the values on cards allows people to move them around visually when sorting and rank-ordering.
1. ACCEPTANCE to be accepted as I am 2. ACCURACY to be correct in my opinions and beliefs 3. ACHIEVEMENT to have important accomplishments 4. ADVENTURE to have new and exciting experiences
Miller, W. R., & Rollnick, S. (2023). Motivational interviewing : Helping people change and grow. Guilford Publications. Created from liberty on 2026-02-09 04:52:17.
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Focusing: a deeper dive 165
B OX 9.1 (cont.)
5. ART to appreciate or express myself in art
6. ATTRACTIVENESS to be physically attractive
7. AUTHORITY to be in charge of others
8. AUTONOMY to be self- determined and independent
9. BEAUTY to appreciate beauty around me
10. BELONGING to have a sense of belonging, being part of
11. CARING to take care of others
12. CHALLENGE to take on difficult tasks and problems
13. COMFORT to have a pleasant and comfortable life
14. COMMITMENT to make enduring, meaningful commitments
15. COMPASSION to feel and act on concern for others
16. COMPLEXITY to embrace the intricacies of life
17. COMPROMISE to be willing to give and take in reaching agreements
18. CONTRIBUTION to make a lasting contribution in the world
19. COOPERATION to work collaboratively with others
20. COURAGE to be brave and strong in the face of adversity
21. COURTESY to be considerate and polite toward others
22. CREATIVITY to create new things or ideas
23. CURIOSITY to seek out, experience, and learn new things
24. DEPENDABILITY to be reliable and trustworthy
25. DILIGENCE to be thorough and conscientious in whatever I do
26. DUTY to carry out my duties and obligations
27. ECOLOGY to live in harmony with the environment
28. EXCITEMENT to have a life full of thrills and stimulation
29. FAITHFULNESS to be loyal and true in relationships
30. FAME to be known and recognized
31. FAMILY to have a happy, loving family
32. FITNESS to be physically fit and strong
33. FLEXIBILITY to adjust to new circumstances easily
34. FORGIVENESS to be forgiving of others
35. FREEDOM to be free from undue restrictions and limitations
36. FRIENDSHIP to have close, supportive friends
37. FUN to play and have fun (cont.)
Miller, W. R., & Rollnick, S. (2023). Motivational interviewing : Helping people change and grow. Guilford Publications. Created from liberty on 2026-02-09 04:52:17.
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166 A Deeper Dive into Mi
B OX 9.1 (cont.)
38. GENEROSITY to give what I have to others 39. GENUINENESS to act in a manner that is true to who I am 40. GOD’S WILL to seek and obey the will of God 41. GRATITUDE to be thankful and appreciative 42. GROWTH to keep changing and growing 43. HEALTH to be physically well and healthy 44. HONESTY to be honest and truthful 45. HOPE to maintain a positive and optimistic outlook 46. HUMILITY to be modest and unassuming 47. HUMOR to see the humorous side of myself and the
world 48. IMAGINATION to have dreams and see possibilities 49. INDEPENDENCE to be free from depending on others 50. INDUSTRY to work hard and well at my life tasks 51. INNER PEACE to experience personal peace 52. INTEGRITY to live my daily life in a way that is consistent
with my values 53. INTELLIGENCE to keep my mind sharp and active 54. INTIMACY to share my innermost experiences with
others 55. JUSTICE to promote fair and equal treatment for all 56. KNOWLEDGE to learn and contribute valuable knowledge 57. LEADERSHIP to inspire and guide others 58. LEISURE to take time to relax and enjoy 59. LOVED to be loved by those close to me 60. LOVING to give love to others 61. MASTERY to be competent in my everyday activities 62. MINDFULNESS to live conscious and mindful of the present
moment 63. MODERATION to avoid excesses and find a middle ground 64. MONOGAMY to have one close, loving relationship 65. MUSIC to enjoy or express myself in music 66. NONCONFORMITY to question and challenge authority and
norms 67. NOVELTY to have a life full of change and variety 68. NURTURANCE to encourage and support others 69. OPENNESS to be open to new experiences, ideas, and
options
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B OX 9.1 (cont.)
70. ORDER to have a life that is well- ordered and organized
71. PASSION to have deep feelings about ideas, activities, or people
72. PATRIOTISM to love, serve, and protect my country 73. PLEASURE to feel good 74. POPULARITY to be well liked by many people 75. POWER to have control over others 76. PRACTICALITY to focus on what is practical, prudent, and
sensible 77. PROTECT to protect and keep safe those I love 78. PROVIDE to provide for and take care of my family 79. PURPOSE to have meaning and direction in my life 80. RATIONALITY to be guided by reason, logic, and evidence 81. REALISM to see and act realistically and practically 82. RESPONSIBILITY to make and carry out responsible
decisions 83. RISK to take risks and chances 84. ROMANCE to have intense, exciting love in my life 85. SAFETY to be safe and secure 86. SELF-ACCEPTANCE to accept myself as I am 87. SELF-CONTROL to be disciplined in my own actions 88. SELF-ESTEEM to feel good about myself 89. SELF-KNOWLEDGE to have a deep and honest understanding
of myself 90. SERVICE to be helpful and of service to others 91. SEXUALITY to have an active and satisfying sex life 92. SIMPLICITY to live life simply, with minimal needs 93. SOLITUDE to have time and space where I can be
apart from others 94. SPIRITUALITY to grow and mature spiritually 95. STABILITY to have a life that stays fairly consistent 96. TOLERANCE to accept and respect those who differ
from me 97. TRADITION to follow respected patterns of the past 98. VIRTUE to live a morally pure and excellent life 99. WEALTH to have plenty of money 100. WORLD PEACE to work to promote peace in the world
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The complex reflections in this conversation also are examples of con- tinuing the paragraph rather than just repeating or rephrasing what the person has said. (See Chapter 8.) Exploring people’s most important values is a good way to develop an understanding of what matters to and moti- vates them, and of the standards that they want to guide their actions.
Maintaining Neutrality
Why would a helping professional ever want to be neutral? It’s a good ques- tion that our editor asked us when reviewing this chapter. Our awareness of the issue really arose through developing MI and realizing ways in which a helper can nudge an ambivalent person toward a particular choice, even inadvertently. Once you are aware that it’s possible to do that, the question arises “Should I do that?”
In many situations, a helper can appropriately choose to avoid tipping a decisional balance in one direction or the other. These are the situations in which people are properly left to make an autonomous choice on their own without nudging. The language above—terms like “should,” “appro- priate,” and “proper”—indicate that this is a matter of ethical judgment.9
Here are several examples: The very first article describing MI posed the illustration of a client trying to decide whether to have children.10 This choice is obviously one that can have major lifelong implications, and to us as parents ourselves, it seems clear that we have no business urging some- one to decide for or against parenthood. We were asked once whether it is appropriate to use MI to encourage people to sign an informed consent to participate in research. Our answer was an unequivocal “No.” How about helping someone consider which medical treatment to choose, or whether to donate an organ for a patient in need of a transplant? Whether or not the interviewer in such cases has a vested interest in the direction of choice, the ethical course of action is to provide a full and fair description of the alternatives and then honor the person’s autonomous choice.
During the focusing process of MI, you may identify issues to be resolved without your favoring one choice over another. Helpers do not always advocate for a particular change. Sometimes the appropriate stance is to remain neutral.11 Your own ethical sense can alert you to situations in
which you believe you should remain neutral and not influence the direction of choice or change.
It is even possible to be unconsciously steer- ing a client in a particular direction by what you ask, reflect, affirm, and summarize. It is therefore
important to be clear about your intention: do you mean to urge the per- son in a particular direction, or do you want to maintain neutrality? You
Sometimes it’s best to remain neutral.
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Focusing: a deeper dive 169
do different things depending on your intention. For example, directional evoking and strengthening of change talk is appropriate in the former case, and decisional balance is more suited to the latter. In either case, the engag- ing, focusing, and planning skills of MI are applicable.
Maintaining neutrality is an important and sometimes overlooked issue in helping relationships. When should you be supporting choice or change in a particular direction, and when would you remain neutral? Be consciously aware of this choice during the focusing task: are you favor- ing directional change, or are you being a supportive neutral party? The most common reason for helping people move in a particular direction is that they have asked you to do so. When that happens, as long as you feel comfortable and competent to help, you have a shared goal to work toward, and that shared focus is an important component of a working alliance that predicts positive change.12 Some helpers, such as probation officers, diabetes educators, and fitness trainers, have specific roles that inform and delimit the particular changes they would pursue. When you have a clear focus and direction for change, the evoking strategies of MI provide some guidance in moving forward (see Chapters 6, 7, and 10).
But what about those situations where your appropriate role is neutral- ity? In four decades of MI research, we have learned much about how to help people move in a particular direction of change. The same research also offers guidance about how not to steer people in a particular direction when you choose to remain neutral. Such directional nudging can happen inadvertently in a conversation without either person being aware of it. Remember that the likelihood of change talk and change is influenced by what you ask, affirm, reflect, and include in summaries. The evoking task in MI involves conscious awareness of this influence and strategic use of these skills to keep moving toward a change goal. Neutrality, then, would also involve conscious awareness of what you are paying attention to and what you are responding to (and how), while maintaining your balance so as not to tip the scale in one direction or the other even unintentionally
The decisional balance discussed in Chapter 6 is a useful model here. The idea of weighing all the pros and cons of a decision dates back at least to Benjamin Franklin, writing in a 1772 letter to a friend who had sought his advice about making a difficult choice.13 Rather than telling his friend what to do, Franklin advised taking a few days to write down all of the reasons favoring each choice. This method was later developed in greater depth by Irving Janis and Leon Mann, who described a way to help people make difficult decisions without influencing their choice.14 In simplified form, a decisional balance can contain four boxes as shown in Figure 9.1. Square 1 in this figure lists the advantages of making a contem- plated change, whereas square 2 contains the advantages of the status quo without change. Square 3 lists the disadvantages of making the change,
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while square 4 is an inventory of the downside of not changing. The same design could be used to weigh any choice A versus B, or even a larger num- ber of options such as A, B, or C.
A person’s present decisional balance indicates their current stage of readiness for change. The more motivations pile up in squares 1 and 4 (advantages of change and disadvantages of not changing), the more likely change is to happen. On the other hand, if motivations in squares 2 and 3 outweigh those in squares 1 and 4, change is less likely to occur. An even balance among the squares is pure ambivalence.
Directional evoking to encourage change (as described in Chapters 6 and 7) gives particular attention to items in squares 1 and 4 (which cor- respond to change talk): the advantages of change and the disadvantages of the status quo. A helper would preferentially ask about, affirm, and reflect motivations in those two squares and, when offering a summary, would include mostly this change talk. This is not to say that you would ignore squares 2 and 3. Ambivalent people may naturally voice material from all four squares, but in the evoking task of MI, you particularly ask for, reflect, affirm, and summarize squares 1 and 4. Doing so can make those items more salient to the person and thus tip the balance in favor of change.15
FIGURE 9.1. A decisional balance.
1 Advantages of change
2 Advantages of no change
3 Disadvantages of change
4 Disadvantages of no change
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Focusing: a deeper dive 171
When you intend not to influence the choice being made, then you would give equal attention to all four squares. That is the original purpose of filling in a decisional balance, so that all possibilities are given equal consideration. Then when a choice is made, people can at least be at peace that they gave full consideration to the possibilities based on what they knew at the time. One way to do this is to literally write down all of the advantages and disadvantages as Ben Franklin recommended. You could use a four- square box for this or simply list the pros and cons of each option. Short of using a written decisional balance, you could keep in mind the four squares, taking care to ask about all four and equally reflecting what people say about each of them, being affirming and supportive of the decision process. If you offer a summary, it would equally include material from all four squares. In this way, you are able to keep your own balance and not unintentionally favor one choice over another.
In summary, focusing is a negotiation process designed to establish shared goals toward which you will move together. Clarifying a client’s life values can inform the focusing task. In some situations you may decide to remain neutral, and to do so involves different skills (e.g., decisional balance) from directional evoking skills. Focusing can flow into and inter- twine with the evoking task of MI, into which we take a deeper dive in Chapter 10.
PERSON A L PERSPEC T IV E : Mapping the Routes for Change
In the early 1990s, I was sitting in the coffee room with a group of academic family doctors, and a wide- ranging discussion opened up about people with chronic conditions who religiously attend clinic and yet never change their behavior despite deteriorating health. “Instead of blaming them, why don’t we try to make a difference?” a colleague suggested. So with a background awareness of MI, we set about studying how nurses and doctors might openly talk about the situation with patients and agree about realistic goals. We devised an agenda- setting chart or bubble sheet that was used to good effect in laying out the choices for health behavior change with them. Looking back, we were addressing the issue of what the focus for change might be. The bubble sheet seemed to take the heat out of the discussion, and people seemed more open about their progress and what changes in behavior might be manageable.16
Clinical practice soon revealed a more subtle challenge with focusing: moment-to- moment shifts in focus during the conversation.
Clarifying life values informs focusing.
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Exploration of audiotapes led to a shift in terminology from agenda setting to agenda mapping, which captured the more fluid nature of shifts in focus. At any point in the conversation, it can be helpful to step back and clarify or renegotiate what the agreed direction of travel might be.17
—Steve
K E Y C O N C E P T S
• Agenda mapping • Neutrality • Self- affirmation • Shared decision making • Value– behavior discrepancies
K E Y P O I N T S
• The focusing task of clarifying goals (what to change) can blend naturally into exploring the why (evoking) and the how (planning) of change.
• Client and helper may have different hopes, and the focusing task works toward developing shared goals.
• Sometimes the appropriate role for a helper is to remain neutral, not favoring choice or change in a particular direction.
• A decisional balance grid can help you keep your balance, giving equal attention to pros and cons when you want to maintain neutrality.
Notes and References
1. Barry, M. J., & Edgman- Levitan, S. (2012). Shared decision making: Pinnacle of patient- centered care. New England Journal of Medicine, 366(9), 780–781.
Elwyn, G., & Frosch, D. L. (2016). Shared decision making and motivational interviewing: Achieving patient- centered care across the spectrum of health care problems. Annals of Family Medicine, 12(3), 270–275.
2. Miller, W. R. (2022). On second thought: How ambivalence shapes your life. Guil- ford Press.
3. Kang, E., Kim, M. Y., Lipsey, K. L., & Foster, E. R. (2022). Person- centered goal setting: A systematic review of intervention components and level of active engage- ment in rehabilitation goal setting interventions. Archives of Physical Medicine and Rehabilitation, 103(1), 121–130.
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4. Danish police, for example, tried to use MI to persuade refugees who had been denied asylum to leave the country. It was not only ineffective but also distasteful to both the interviewers and the refugees. Kohl, K. S. (2022). The stalemate: Motiva- tional interviewing at a carceral junction. Incarceration: An international Journal of Imprisonment, Detention and Coercive Confinement, 3(1), 1–18.
5. Maslow, A. H. (1970). Motivation and personality (2nd ed.). Harper & Row. 6. Rokeach, M. (1973). The nature of human values. Free Press. 7. Epton, T., Harris, P. R., Kane, R., van Konigsbruggen, G. M., & Sheeran, P. (2015).
The impact of self- affirmation on health- behavior change: A meta- analysis. Health Psychology, 34(3), 187–196.
Steele, C. M. (1988). The psychology of self- affirmation: Sustaining the integ- rity of the self. Advances in Experimental Social Psychology, 21, 261–302.
8. Kirschenbaum, H. (2013). Values clarification: Practical strategies for individual and group settings. Oxford University Press.
Rokeach, M. (1973). The nature of human values. Free Press. 9. Miller, W. R. (1994). Motivational interviewing: III. On the ethics of motivational
intervention. Behavioural and Cognitive Psychotherapy, 22, 111–123. 10. Miller, W. R. (1983). Motivational interviewing with problem drinkers. Behav-
ioural Psychotherapy, 11, 147–172. 11. Miller, W. R. (1994). Motivational interviewing: III. On the ethics of motivational
intervention. Behavioural and Cognitive Psychotherapy, 22, 111–123. We also dis- cussed this issue in more detail in our third edition of this book.
U.S. National Commission for the Protection of Human Subjects of Biomedi- cal and Behavioral Research. (2017). The Belmont report: Ethical principles and guidelines for the protection of human subjects of research. Forgotten Books.
12. Horvath, A. O., & Greenberg, L. S. (1994). The working alliance: Theory, research, and practice. Wiley.
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta- analytic review. Journal of Con- sulting and Clinical Psychology, 68(3), 438–450.
13. Franklin, B. (1904). Moral or prudential algebra: Letter to Joseph Priestly (Septem- ber 19, 1772). In J. Bigelow (Ed.), The works of Benjamin Franklin (Vol. V): Let- ters and misc. writings 1768–1772. Putnam.
14. Janis, I. L., & Mann, L. (1977). Decision making: A psychological analysis of conflict, choice and commitment. Free Press.
15. Glynn, L. H., & Moyers, T. B. (2010). Chasing change talk: The clinician’s role in evoking client language about change. Journal of Substance Abuse Treatment, 39(1), 65–70.
16. Stott, N. C. H., Rees, M., Rollnick, S., Pill, R. M., & Hackett, P. (1996). Profes- sional responses to innovation in clinical method: Diabetes care and negotiating skills. Patient Education and Counseling, 29(1), 67–73.
17. Gobat, N., Kinnersley, P., Gregory, J., Pickles, T., Hood, K., & Robling, M. (2015). Measuring clinical skills in agenda- mapping (EAGL-I). Patient Education and Counseling, 98(10), 1214–1221.
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