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My blog for health care providers using MI about the process of change!

In a Pinch: 4 Tips to Strategically Respond to Discordant Behavior

It happened again. Your client squares off with you. He or she says something that caused your body’s alarm to go off (such as, “Why do I have to work with YOU?” or “How are YOU supposed to help ME?!?!” or “I hate having to be here. This is SUCH a waste of my time”).
The hairs rise on your back. Your heart skips a few beats and then starts to pound in your chest. Your leg muscles become tense. You grip the arms of your chair as you shift back. Your brain fight/flight/freeze response is telling you to be on the defense. You wonder how, “How in the world am I going to work with THIS client?”
One of the most common questions during my Motivational Interviewing workshops is, “In this situation, how do I turn this off to stay in the moment, be present with my client, and respond?” Helpers really want to feel more effective in managing these very tough situations.

Research tells us that the way we relate to our client can change the course of the session (Miller & Rose, 2009). Here are 4 tips to remember that may help you move through this situation more smoothly.
1.  Breathe!!!

Give yourself a big belly or “balloon” breath, a natural resource to activate your relax response…a gift from our beloved parasympathetic nervous system.
2.  Ask yourself, “What is the client REALLY saying?" Humanize it.  Reflect it.

What is the client’s underlying message? Maybe the client is really trying to say, “I’ve been burnt so many times, that I don’t trust people to protect myself” OR “I’m scared to trust you. I’m not sure you can help me here.” OR “I feel ashamed of myself that I have to be in treatment. I feel overwhelmed.”
Clients relate to helpers in the same way they relate to others in their lives. Humanizing their behavior facilitates our empathy. Use this empathy in your reflections to convey understanding—BEFORE using any questions to further understand the client’s perspective.
Unlike questions, reflections promote an atmosphere of acceptance, which builds a sense of safety in the room and facilitates rapport. Even if the client continues to show spikes of discordant behavior during the session, reflections can help the client to feel understood, and over time, dissipate the discord.
3.  Emphasize the client’s autonomy.

Highlighting the client’s personal choice is a part of the Spirit of MI, as well as an ethical responsibility. Identify the client choices or a menu of options. You can also state the potential consequences for action or inaction. For example:
C: “What if I don’t complete treatment (or this evaluation) and leave now?”

H: What you do here is really up to you. You can leave now and potentially face (A, B, C) consequence (speaking to Sustain Talk) OR you can stay, we can finish our meeting and get things moving along (speaking to Change Talk). It’s your decision and I can’t make it for you. I wonder what you’ll do?”
Then, use silence.
4.  Highlight and cultivate change talk. 

Begin to shift the direction of the conversation toward change AS SOON as you hear Change Talk. Use open questions, affirmations, reflections, and summaries (OARS) to strategically highlight ANY language in the direction of change, even if it sounds like:
C: “Well, I’ll stay and ONLY so I can get you all off my back.”

C: “This is so stupid that I have to be here, but I’ll finish the session if I can start to get this situations behind me.”
C: “I’m not sure whether this will help at all, but I’m willing to give it a try.”
Dancing with discord saves us energy as helpers because we’re not trying to “fix” the situation or the person (even though we cannot). Rather, we strategically flow with it to help dodge roadblocks in communication. 
How do you use MI to diffuse discord? Leave your comments here (a friendly reminder: please do not share any Protected Health Information). Thank you!

Citation: Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing. American Psychologist, 64, 527-537.

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