I believe it is important to start by discussing how Motivational Interviewing initially thought about disharmony between a client and a clinician as they explored change. When the first edition of Motivational Interviewing: Helping People Change by Miller and Rollnick was released, the term 鈥渞esistance鈥� was chosen to represent the phenomenon of disagreement, tension, or 鈥渘ot being on the same page.鈥� The key here is that that the responsibility for disharmony in the therapeutic relationship was almost always placed on the client, and never the clinician. However, 鈥渄iscord鈥� can sometimes be caused by our mood or approach. Perhaps like any other human being, we may feel tired, stressed, overwhelmed, or distracted, and may bring some of these experiences into our sessions with our clients. It may also be that we, as clinicians, are working harder than the client, wanting change to occur badly for the client, and/or we are trying to move the client along faster than they are ready.
The way it was suggested to respond to this 鈥渞esistance鈥� was to 鈥渞oll with resistance鈥� by reflecting what the client was saying, perhaps asking an opened ended question about their concern, and to explore this 鈥渞esistance.鈥� In the most recent edition (3rd) on MI by Miller and Rollnick, they have used the term 鈥渄iscord鈥� to describe this phenomenon that can exist between the client and clinician. It is important to note that 鈥渄iscord鈥� involves both parties and that it is like a fire (or at least smoke) in the therapeutic relationship.
Interestingly, responding to 鈥渄iscord鈥� in an MI-consistent way is similar to how we have been talking about 鈥渃hange talk鈥� and 鈥渟ustain talk鈥� in that we often reflect back what the client has said, ask an open-ended question, and spend some time exploring what could be occurring in the relationship. For example, if the client was questioning an age difference between you and them, a sample response from Miller and Rollnick may look something like this:
CLIENT: How old are you? How can you possibly understand me?
CLINICIAN: You鈥檙e looking for some support, and you鈥檙e not really sure if I鈥檓 the right person to provide it.
CLINICIAN: If someone was able to help and support you, what would they ask you about or what would it look like if someone was able to understand you?
Again, in this example, there appears to be some concern on behalf of the client that may signal some 鈥渄iscord鈥� in the relationship. At the same time, if we, as the clinician, step on our client鈥檚 toes or say something that was insensitive or perhaps hurt the client鈥� feelings, we can simply say we are 鈥渟orry.鈥� It acknowledges and models that we are taking responsibility for our actions, that we are invested, and that this relationship is important. Examples from Miller and Rollnick include:
鈥淥h, I鈥檓 sorry, I must have misunderstood you.鈥�
鈥淚t sounds like I must have insulted you there.鈥�
鈥淚 didn鈥檛 mean to lecture you.鈥�
So, when there is 鈥渄iscord鈥� we need to remember that it involves both parties and that the focus is on the therapeutic relationship and not the behavior. However, the way we respond in an MI-consistent way is similar to how we respond to 鈥渃hange talk鈥� and 鈥渟ustain talk鈥� by reflecting back what the client has said, asking an open-ended question, and spending some time exploring what could be occurring in the relationship. And by responding in this way, it is likely to keep the client engaged in the possibility of change and increasing trust in the therapeutic relationship.
For more information about Motivational Interviewing or related services, contact Eunice Akinyi Okumu, by phone (919) 843-2532, or by email, eunice_okumu@med.unc.edu.