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Compassion in a T-Shirt
Using Motivational Interviewing to Create Change With Families | Doug Smith
01:06:21
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- [00:01]
A
Hi, I'm Dr. Stan Steindl and welcome back to Compassion in a T Shirt, where we explore the science and practice of compassion and how it shows up in real human relationships. Today I'm really pleased to be joined by Professor Douglas Smith, a colleague and friend through the Motivational Interviewing Network of Trainers. Doug is professor of Social Work at the University of Illinois at Urbana Champaign and Director of the center for Prevention Research and Development. Doug's work sits right at the intersection of compassion, evidence based practice and real world family complexity. For nearly three decades, his clinical and research work has focused on substance use prevention and treatment, particularly with adolescents, emerging adults and families navigating significant challenges. He's a licensed clinical social worker, a long standing member of the Motivational Interviewing Network of Trainers, and someone deeply committed to understanding not just whether interventions work, but how change actually unfolds in conversations. In this conversation, we'll be talking about Doug's book, Motivational Interviewing with Families, which brings together theory, practice, case examples, and a reimagining of how MI can support families as systems, not just individuals. And so I bring you Professor Doug Smith. Professor Doug Smith, welcome to Compassion in a T shirt.
- [01:41]
B
Thanks for having me. It's great to be here.
- [01:44]
A
Congratulations on the book Motivational Interviewing with Families and published last June. I actually wondered, can we start with the idea of family work? I guess like what is the therapeutic or the helping context that you have in mind in the book?
- [02:02]
B
It's a great question. So I wrote the book with a goal in mind of it being broadly applicable to people that consider themselves proper family therapists, but also just people that have regular contact with family members through their practice. And so some, some as I was talking with my editor, they were thinking, you know, there's probably a lot of people that would never consider themselves family therapists, but they do regularly interact with, with family members when they're, when they're treating clients. And so I wanted to have, you know, very, very broad definition. So any, I think I define family work as anytime, you know, a clinician or a helper is coming into contact with family members on behalf of their, on behalf of their clients.
- [02:52]
A
I guess it could be sort of couples, it might be sort of family members with their kids, it could be the children of older age clients that are coming along to sessions. You know, sort of anything really might count as family work.
- [03:07]
B
All, all of the above.
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A
Right.
- [03:09]
B
And in fact, I. One of the later chapters, and I have examples of all of the above. And in the book, and we talk, one of the later chapters takes the later two chapters take kind of a lifespan approach where we review a lot of the family based studies that have been done with ranging with, you know, parents of young children all the way to older adults and their adult children. So a lot of different constellations.
- [03:40]
A
So from the MI point of view, bringing MI to working with families, sometimes people hear MI and, and sort of feel like, well, you know, that's what I already do or, you know, that sort of a thing. And, and they hear the, the, the, the counseling skills that do underlie it. And we probably talk a bit about that in a sec. But there's a, there is an art to, to, to creating a kind of a direction in the conversation, I guess. And I imagine that's, that's kind of, kind of complicated with families because there would be multiple, multiple ideas and preferences and motivations and so on at play and sometimes heading in different directions and that sort of thing. And so I can only imagine that the intentional, the directional aspect to mi, it takes a bit to kind of find that and kind of collaborate in such a way that we're, we're sort of moving in a direction or what would you say about that in terms of family work?
- [04:44]
B
I think you hit the nail on the head with using MI in a family context. One of the big problems is that when you're doing family work and there's multiple people in the room, you have to direct traffic and so you have to think part of the problem. So motivational interviewing asks practitioners to listen deeply to their clients. And now rather than listening deeply to just one person, I'm listening deeply to a family system and I'm trying to think of multiple perspectives, I'm trying to think of multiple motivations and I'm trying to guide that all towards some sort of productive work, whatever we might work on together. And so it is a little bit complicated. I think the part of the, you know, my initial training as in my initial work in family therapy and some of the early experiences I had are kind of reflected in my writing in that I've seen a lot of what I refer to as doing individual therapy while the family just happens to be sitting there as passive bystanders. So doing kind of like a, you know, doing individual therapy with, with a, with an audience, which I really wanted to impress upon people that that's not really, you know, leveraging, you know, the, the, the wisdom of the family in the best way. Like we, we, we really can gain a lot from family members perspectives. And the, the reality is unless you're a Family therapist. You're, you're seeing individual clients and know there might be specific reasons for bringing families in. But you know, we, our family members are people who are around us way more than clinicians ever will be. They know so much about us. They have different perspectives and of course they're going to see things differently and say different things. So it is, it's a, it's a very interesting activity. But yes, it's, it's tremendously complex to be thinking about using MI skills with family members.
- [07:01]
A
I'm not sure whether this is a sort of a tough question for you or one to sort of throw at you, but what would it actually kind of look like? I mean, if you were to sort of imagine a family and what an interaction might sound like? Is it sort of that the practitioner is sort of asking questions of that person and then reflecting and then reflecting to the other? Like, can you just. Yeah, give us a play by play as to what it sounds like when MI is not just MI on the one person with other people watching, but it's a kind of a family based motivational interviewing session.
- [07:39]
B
I didn't go so far as prescribing a number of interactions you had to have with each family. There's a couple of different ways you can think about this. How many times am I talking to both family members? You know, how many speaking terms do I take with the, with the, with one individual? And I've got a couple of examples in the book that actually lay this out. Like I have a, I have a example, I've two different examples of basically the same couple and they're coming to, they're coming to a clinician for, for mediation post. So this is a post divorce situation where they're trying to figure out arrangements for their children which, which happens in, in a lot of countries. And in the first example I kind of demonstrate what it's like to have all the conversation flowing through one person and in the second one, and I, I put actually a graphic where you see what, how many specific terms turns did they take with each individual person? And so a couple of ways to do that and a couple of the, you know, talking about the techniques. But you know, quite simply there's a couple terms that I, that I used in the book, like pivoting. I use the term pivoting to kind of explain this concept of you really have to be mindful of talking to one person and then pivoting to the other person, you know, on a fairly regular basis so that they're not just Sitting around and becoming disengaged.
- [09:22]
A
Yes. It's interesting because in MI we often do frequency counts of things. We might sort of count up how many open questions and how many reflections and there's the question to reflection ratio sort of thing, or reflection to question ratio 2 to 1 or something like that. And then in a family sort of setting, there might be. Be this other kind of thing to keep an eye on, which is the turns, the turn taking or the pivoting and exploring sort of both parties a little bit. And part of that might be exploring their own perspectives, part of that might be each person responding to the other's perspective, I guess. But it becomes interesting when we start to think about behavior change and maybe even change talk, which we'll talk a little bit about later perhaps, but, but the, the change talk would be when a person is talking about their own kind of motivations and, and kind of what they would like to change or why or how and so on. Rather than what I often find is each party starts to talk about what they'd like the other person to change and why and how and so on. And I'm guessing that's not quite the same as change talk, but so, so it's all. It's sort of juggling those kind of ideas.
- [10:44]
B
Well, I think it depends. So it's, it's an interesting thing to think about. If you're thinking at the family systems level, then, you know, we have this idea that change talk. When clients talk about their motivation to change and is it. It's yoked to a particular target behavior, you know, something, something specific. When you get to family systems, a lot of time what you just mentioned really happens. It's like, I'd like them to change this or I'd like them to change this or their behavior is causing me to do this. You know, it's affecting me in this way. So I've been thinking about how do we. Is there a way to think about like a family level target behavior? Is there some broader, like, overarching family behavior? Like, like I do a lot of work in, in addictions. And so, you know, clearly the target behavior is usually reducing substance use or, or mitigating the harm from substance use, those, those types of things. But if I bring a parent or a, you know, a partner in, then the conversation often shifts to family functioning and how this is affecting family functioning. Now, in classic MI, individual MI perspective, everything that the partner would say about family functioning would be subordinate to the goal of changing their substance use. Like, yes. Oh, if they, if they were to, you know, cut back on the booze, we'd have better communication. You know, things would be a lot better. We'd be happier. So then I guess the question is, do we think about family functioning or family communication as kind of like the top family goal and then substance use as kind of a secondary change talk? So it's a little bit complicated because what you have is you've got interlocking goals, essentially. You can't really separate family functioning goal from the substance use goal. They're so interconnected. It really is. Which bucket do we want to put this under? And I tried in the, in my writing to kind of think a little bit about this and think about, you know, should we be double counting some change talk? Should we be thinking of some change talk belonging to both someone's personal goal and also a broader family goal? So in that situation, like family, like somebody that would be changing their, their substance use, that would be their, that would, that would essentially be kind of their individual target behavior. But if that also paves a way to talk about kind of in, in family work, if that paves the way to talk about this, this higher order goal of improving someone's family, then you know, those, those are, that would, I would kind of put that as a family level target behavior. And I would think about whether those, whether any change talk statements belonged to both of those types of target behaviors. Hopefully that makes sense. Hardest chapter to write. That was probably to write in the book. And I had to take a lot of creative liberties because it's one where we don't really have a new model. We don't have a model for it. So, you know, we're, I was really trying to think, think, think a lot, think a lot about it.
- [14:45]
A
Yes, it's, it's sort of the, the novel contribution really of the book is, is this, this idea of how to kind of manage the, the different people, their different goals, their different motivations. It's interesting to think there, there is a, an individual or personal goal perhaps for the, maybe the person who's identified as your client. I guess the person who perhaps is, is working towards changing their drinking or something like that. There might also be personal change goals for the, the other family members as well. That, that there, there might be things that we explore that they're doing. Perhaps that's sort of kind of, you know, creating difficulties or contributing to the, the maintenance of the behavior even. Or perhaps there's certain boundaries that they could explore, you know, setting or changing for themselves and, and Then there's the, then there's the kind of family, the overarching focus for the family and what together we might all change or you know, that's more at that family level. And there might even be, yes, very, very sort of reciprocal focuses as well, that this person might be changing something and this person's changing kind of the opposite of that. But the two things that are maintaining and creating a bit of a self perpetuating cycle or dynamic between the parties. I'm just sort of riffing off what you were saying and thinking out loud. But there's multiple potential focuses really of any one conversation.
- [16:27]
B
Yeah, I think so. And even as I was drawing out Venn diagrams, thinking about, about it, thinking about what words I wanted to use, I, I landed on, you know, family level change talk. I landed on a multi level change talk, which is the kind of how I define that is if, if someone has a goal like quitting drinking was, let's just keep going with that example. And that goal is both a personal goal and also contributes to the broader family goal of, you know, improved family relationships, then, you know, it would, it would kind of double count as change talk onto two different target behaviors. So that was, that was kind of my thinking. And then I think, you know, and then maybe there's things that people want to change that really don't kind of match. Then, then you've got to be careful about. Like how much time do I allocate to talking about someone's personal change talk that really doesn't map onto the broader family conversation? Because that might be distracting and it might pull us back into this idea of doing individual MI in front of their family member.
- [17:50]
A
The MI practitioner really is the serene duck on the water with their legs going 10,000 under the surface. There's a lot to be listening out for and I, I can imagine that those, you know, the, the vibrant kind of energetic family session is, is, is somewhat exhausting too for the practitioner as they, as they focus on all of these levels. But you, you emphasize reflective listening. Actually you kind of reordered things a little bit here, which I thought was interesting.
- [18:22]
B
You, you have acronym heresy, right?
- [18:25]
A
Acronym heresy. The, you, you've sort of changed it to raws, reflections, open questions, affirmations and reflective summaries. How do you think the MI community or the MI trainers community is going to respond to your new acronym?
- [18:45]
B
Well, hopefully. Well, it's still, still, it's still playing itself out. I, when I was at the last network of trainers meeting, the last MINT meeting in Minneapolis, I had someone say, oh, my gosh, I love that. And I was like, oh, thank God. Because I was, you know, I, I felt like I was taking a leap with, with reordering things. And I was, you know, had a little bit of creative license to do that. You know, the main point, of course, I was trying to make is that, that if we have reflections, as, you know, if we truly want MI to be very reflection heavy, which is kind of the quality assurance standards are using more reflections than questions. Why aren't we emphasizing that? Why do we start with questions in the acronym? That just seemed a little strange to me. And then the other thing is that people get confused about summaries because when we're doing quality assurance, summaries are, even though it's an S, they're really, we, we talk about them out of both sides of our mouth. They're summaries are summaries, but they're also reflections, you know, so it was, it made sense to me to, to, to reorder and to, to do that.
- [20:10]
A
Yeah, no, I, I, I, it made a lot of sense to me as well, you know, because we, we often.
- [20:15]
B
I haven't had any hate mail. I haven't had any hate mail about it yet. So I'm glad about that.
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A
Oh, well, sometimes it's still early days.
- [20:24]
B
It's still early days, though.
- [20:26]
A
Could be, could be fun. But no, it does make sense, you know, that we're often in training trying to, you know, sort of, if, if motivational interviewing were a car, then reflections of the engine type thing, you know, like there's these little ways that we emphasize the importance of reflections in mi. Open questions are important and get things started and affirmations kind of perhaps sweeten the deal a bit or something. But reflections of the engine type thing, so to put them up first, you know, makes a lot of sense, really, when working with multiple people. Because it sounds like in some ways that that idea of raws really applies to motivational interviewing generally. But in terms of working with families, what, what reflections really allow us to do or what do they kind of help with or achieve, you know, that maybe, you know, some of those other skills, the questions and affirmations and so on, maybe don't.
- [21:26]
B
I think, reflections when you, when you deliver them at the family level. And so the cool thing is that it doesn't really take much effort to direct a reflection to two people rather than one person. When I was writing, I found it remarkable. And when I was thinking about my own practice, I was like, of course you know, there's an easy way to train this. And I was thinking about training and I was thinking about my practice and what I, what I've done with families and couples when I've seen them. And I was thinking, you know, all we really need to do to a reflection to, to get to this goal of monitoring the balance of time and making sure both people are talking. We can direct a reflection to multiple people by just adding a little clause of like. It sounds like all of you are feeling frustrated. It sounds like all of you are committed to doing this just by adding all of you, both of you, everyone in the room tonight, you know, just a little bit of a minor variation to like a reflection stem. And all of a sudden you're, you're opening a space for anyone in the room to, to talk rather than routing your conversation through just one person. So that, I think is the benefit of, you know, reflections. The other thing is, you know, it gives you an opportunity to reflect on the commonalities so that the common ground, if there's a tremendous amount of conflict, you know, you can really focus your reflection on, on what, what are these, you know, conflicted, you know, family members that, that are in conflict? What are they all, what is their common purpose here? And you know, we, we often talk about, you know, sometimes, you know, one of the classic reflections or ways to think about people who are like, oh, I'm not happy about being here is, and yet you came, you know, why did you all come and agree to come here? What's in it for each of you for being here in the room together to work through this and that. That, I think, is where reflections and the open questions are really valuable, especially when they're addressed to multiple people at one time.
- [23:57]
A
That's a really great takeaway, a little trick there of reflections that begin with you all or everyone here. It's kind of like a reflection of the various parties, but where the common ground lies. I can really sense that you all feel quite committed to do something to make life in the family better. And they're, they're all coming at it maybe from different angles or they have different roles to play, but that's the common ground. And you're able to use reflections to, to kind of bring that sense together. I wonder where. What about the good old double sided reflections? You know, often in double sided reflections we might reflect the individual's ambivalence. I guess. On the one hand you feel this and on the other hand you feel that or, you know, and so on. Is There a kind of a, a way that double sided reflections get used or changed or kind of applied in a family setting.
- [25:02]
B
Wow. It's, it's as if you're a confederate. Like, like that's a great question. Thanks for that question. Because it, it, it really, you know, it's something that I, I, I labeled a double, a family level double sided reflection. Love it. And how it can be used is, rather than in a, in a individual level double sided reflection, you're trying to highlight both sides of a person's ambivalence. But in a family level double sided reflection, what you can do is you can highlight two different people's perspectives. So it sounds like you're feeling this way about this and on the other hand you're feeling this way about this. You know, so where does that leave us? You know, that, that kind of, you know, it is. And again, it's another strategy for communicating to both parties that you're listening to them both, that you're not taking sides, that you're, that you're really wanting to work with them as a unit. And that's, that's one of the big problems in, with engagement in family work is that usually somebody feels like they might be scapegoated or someone, someone, someone might be a little bit less invested in it or someone might feel that they're going to be, you know, that the, the, the clinician is going to take sides with someone else and they're going to be the focus of, you know, everything's going to fall on them essentially.
- [26:36]
A
I, I wonder whether there's another one which you may have come up with too. But it's almost like a triangular reflection where you reflect this person's perspective, you reflect this person's different perspective, and then you reflect the bit that is the common ground that sort of is the third kind of aspect of the reflection. And I was thinking that because in a double sided reflection we often choose which part of the ambivalence to put last. You know, we might put the change talk last or something like that. Right. And so putting the common ground last was just a, I don't know if, if triangular reflection is the right kind of term to use, but you know, something like that.
- [27:20]
B
Well, you've given me a lot to think about for the second edition. Hopefully I'll hit you up in like five to ten years with yes. Yeah, come back to me. That's, that's a really great thought though. I love that. So that, that would be, I could, I could definitely see some, some Use to that. Yeah, yeah.
- [27:42]
A
No, it's. It. It just really speaks to the. Well, to. To the. The importance and. And the helpfulness of. Of reflections, you know, that. That these are the sorts of things that reflections really do achieve, that asking lots of questions might not. You know, the. The other thing, of course, is that reflection of the different people might hear and understand each other as well. And so that you're kind of serving that purpose too. So the reflections seem to be very important.
- [28:16]
B
Oh, absolutely. I mean, as you mentioned, they're generally considered to be the engine of mi. And I was just teaching master's level social work students this week and had a class. We were covering reflections and complex reflections this week. And, you know, we talked about what is it like to guide a session with primarily reflections. What are some of the challenges in doing that and what are some of the benefits of doing that? And I think, you know, some of. Some of what we got are that questions, sometimes questions I think just have more potential for error in terms of miscommunication. So that's kind of how I've been. How I was thinking about it this week as I was teaching. I was like, you know, there's. There's potential for a question to come off badly or for a question to, you know, have a little bit too much of an assumption or, you know, sometimes questions are actually suggestions. So, you know, we. I do a fair bit of differentiating between reflections and questions because my students sometimes say things like, have you thought about getting a job, you know, to someone who's struggling financially? Or I'll see this in role plays with beginning clinicians. And, you know, of course, our client who's struggling financially has thought about how to better support them. You know, they don't necessarily need that. That suggestion. They need, you know, sometimes they. They just need a clinician that's going to validate them and build, you know, someone that they trust to, you know, troubleshoot and walk. Walk through, walk with them and to, you know, feel their. Their. Their pain and to understand their pain and their struggle. You know, that's really what, you know, I love. I love the. The. Your focus on compassion's always been refreshing. And, you know, I mentioned that with the. With the new terminology and motivational interviewing about compassion, caused me to go back to the dictionary and look at the Latin roots of compassion. And it literally means with pain. Right. With someone to be with someone's other, with someone else's pain. So it's walking with them through that, through those challenges.
- [30:45]
A
Yeah, questions. They're important too, I suppose. But it's the reflections that really help to build the spirit of MI and also, you know, just clarify understanding. Because in some ways the, the danger of questions really kind of comes in when we assume that we know what they mean by their answer. And we, you know, the answer comes and, and unless we then offer a reflection or a complex reflection and kind of just make sure and kind of clarify if we need to or whatever, then. Then we're left with an assumption that we know what their answer really means. And I suppose in family work, family members can make that sort of similar mistake too, that their partner says something and then there's all this history and other things have happened and these layers of assumption that they know what the person's saying and sometimes they're offended by it or whatever. But to use the reflections to really create greater understanding and therefore greater helpfulness, as they say.
- [31:56]
B
Yeah, and I think you're absolutely right about that if you make it as a humble hypothesis. And I think there's that rush. A lot of motivational interviewing is about avoiding that rush to diagnose and to prescribe. You know, these are some of the words that we, that we try to avoid or they're a little antithetical to motivational interviewing though. You know, if you think about some of the words we commonly use, collaborate and accept and you know, demonstrate compassion and partner with. We really are trying to make humble hypotheses through reflections and to, you know, and if we're wrong, we self correct and our, and our clients will tell us. No, it's not necessarily that. I don't, I don't think of it that way, but I think of it this way. And then you've, you've, you've opened up communication. You've. You're talking about something in a, in a different way.
- [33:01]
A
The thing that's still sort of there in my mind, I think is just the notion that the different members of the family will have in mind different focuses, different pathways, different outcomes and how to manage that. I suppose you mentioned in your book sort of like faux autonomy, where you sort of respecting choices and kind of being collaborative and so on to, to get them to do what you want or to get them to make the change. It's a kind of a. As opposed to, you know, how do you offer that genuine respect and autonomy support and so on for families choices and then the individuals in the family's choices and sort of staying compassionate, staying collaborative, as you say. But just when family members might want different things.
- [34:05]
B
It's a really good question. And, you know, sometimes family members do want different things. Sometimes they seek counseling and they dissolve or they, you know, become estranged. And I think, you know, that's the messiness of working with people, right? It's like we as clinicians can't make everything better for our clients. And I think the, you know, the point about, you know, showing compassion for people and, you know, you asked about autonomy, like, how do we respect autonomy when things go poorly? I think it requires a lot of. A lot of acceptance on the part of clinician about just how much control we have over outcomes and just how much we can actually do on this person's journey. And, you know, I think that's probably one of the hardest things in my training was how do you not take it personally when things go badly? And how do you maintain that composure when family members aren't doing what you want? That's a challenge to showing autonomy because, you know, there's a. There's a tendency to kind of go into I told you so thinking or like, it just reinforces your idea that, you know, if only they would do this, things would be better. But, you know, at the end of the day, I can't control that as a clinician. I can be genuine with my clients. I can. I can, you know, I can offer them, you know, I. If I get the privilege of entering someone's family system and they share with me, you know, the messiness of their family and things don't go well, I have to accept that something happened. And hopefully, you know, hopefully it was a. It was a planting seeds moment. Hopefully this was. Maybe I wasn't the last stop on their journey, but I think, you know, this is. This is why I stress when we're. When we're kind of. I think this definitely comes up when if we. We prematurely end our relationship with family members and things aren't going well. You know, I talk about ending on empathy and, you know, kind of this idea of it happens, you know, not, you know, family. Family work doesn't always end on a. On a positive note. And what we need to do to kind of plant that seed is to make sure that we're, you know, were still being empathic to their situation, still there with their. With their feelings and acknowledging their frustrations that things didn't go well because it's. It's rough. And I think it's rough on clinicians emotionally, too.
- [37:25]
A
And just listening to you there, I sort of.
- [37:28]
B
You.
- [37:28]
A
You sort of reminded me really, that in some ways this is the point, actually, is that, you know, families are there because they have different perspectives and different views of where to from here. And in a sense, the genuine autonomy support, the accurate empathy, the using reflective listening at a family level and individual level and all that sort of stuff is all designed to help with that. You know, sometimes it might not go well, as you say, and then we're sort of managing our own feelings and responses to that and our own frustrations and so on. But often the, you know, applying the motivational interviewing approach and sort of listening well is the very thing that helps to find or helps families find their way through those tricky sort of dynamics amongst them. And in a sense, that's the hopefulness of your book. And the approach, and bringing that approach to families is to help them through those. Those tricky bits.
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B
What.
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A
What is family level equipoise?
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B
This actually goes back to the idea that kind of the balance of. We talked a little bit earlier about the balance of talking to two, two or more people in the room that we have to divide our attention between multiple people. We also can't. I think one of the, you know, the pat myself on the back moment was when I wrote something, I wrote a sentence, and I know you're a writer and occasionally you're like, oh, my gosh, that's it. I like how I wrote that. One of the things that I really liked in the book writing, and I still reflect on it, is, you know, you can't have one person's affirmation be another person's confrontation. You know, you just simply can't if you've got a family in conflict. And I think it's particularly tricky with affirmations. Affirmations, you know, if. If you have a family in conflict and, you know, one person doesn't see any problem with their behavior, and you've got a clinician that's trying to build rapport with them, let's say, in front of a family member they're in conflict with. If you're pouring on affirmations to, you know, this family member, then the other family member jumps in, it is ready to fight. You know, it's like, I don't see it this way. You know, you're. You're discounting my perspective. So the idea of family level equipoise is really thinking about that family dynamic and thinking about that perspective and really being mindful of evenly applying the motivational interviewing spirit to everybody that's in the room.
- [40:20]
A
Yes, we're really wanting to avoid sort of the. The leaning one way or another, or kind of having alliances accidentally even or unwittingly with. With different party family members and. And trying to be equally poised, I suppose, across the. The different. Well, across the different people in the family and across the different parts that each of them perhaps also have. You know, I. Some reason I'm not an internal family systems person, but I keep thinking about how in mi we're sort of working with an internal family system and in family work, we're working with a family system, I suppose, and it's sort of. Right, so we're trying to always have the different people and different parts, you know, in equipoise, I suppose. Yeah.
- [41:14]
B
Yeah. I think, you know, part of why I coined that too, is I'm trying to encourage people with some MI background to integrate more family work into their practices if they're primarily focused on individuals. And so I think the MI community, the folks in the MI community that read the book, I hope that they kind of get that point. I use the word equipoise specifically because it's something that they're familiar with with regards to change talk. But, you know, I switched it up and am referring to equipoise in regards to the family system. And I did that with a. If you think about it, I did that with a couple of different terms. You know, the family side of double reflection is not reflecting both sides of the ambivalence, it's reflecting two or more perspectives of different family members. So it really, you know, I was hoping that that would help make some connections for people in the MI community to expand their practice and do a little bit more family work or help them be a little bit more comfortable doing that.
- [42:25]
A
Yeah, expand was the word that was in my mind too, that in a sense that it expands MI to the family, but it also expands particular parts of MI to sort of apply to a. To a. In a family kind of a setting. Which brings me to change talk. And, and, you know, so in the context of family work, what. What are we. How are you really thinking about change talk there? And, and what. What does it sound like if we're hearing it from the different parties? Are there things that we're sort of watching out for there in terms of. Is sort of noticing and, and reflecting the change talk side of things?
- [43:08]
B
I think this is where you can really. This is exactly why I think some individual practitioners should consider working with family members, because you have the potential to generate and clarify goals of multiple people at once. And so, you know, there are some scenarios where I think I talked earlier about like interlocking goals, you know, improving family communication and reducing drinking. And you know, you know, there, there are just some situations where during the course of the conversation two people might have ideas of, you know, different things that they could change to solve problem. And then you're generating kind of two people, two different people's motivation, but you're also learning about them as people and you're also learning about what they want. And so you're actually identifying other goals. So sometimes it's like, it's kind of like this, this, this idea that we, that we've had in, in cognitive behavioral therapy for, for decades, that small changes lead to, you know, bigger changes, that sometimes there's this cascading of changes. Well, if you're working with families and if you're, you're kind of generating change, talk about different goals, I think sometimes that has a great possibility to cascade. You know, one of the, one of the examples in the book that, that I talk about is, is a child truancy example. And like parents are school social workers called in to talk to two parents about, you know, getting their, getting their kid to school on time. The kid's actually not there, but we could have had the kid in the, in the room too to kind of talk about this. Again, going back to this idea that that's family work, right? It's a situation where you're, it's not family therapy proper necessarily, but you're having, you're asked to work with family members on a specific problem. A kid's not getting to school on time, but you can do it in a way where you really have a big impact on the parents too, rather than just solving this problem of like getting a kid to school on time. You know, I've got some sample dialogue about how one of the case examples has some sample dialogue about when they're generating change talk. You know, the mom is thinking about switching jobs because that's a contributing factor to the child not getting to school on time. And so the conversation kind of veers to that, what that would look like for mom. And so we can have these relatively short mi conversations with families that even if they're designed for one purpose, they, they can kind of have an impact on a broader family system.
- [46:20]
A
Yes, it's really sort of listening out for change talk in a very open hearted, open minded way, I suppose. And depending on the comments and the things that people sort of say or the things that you notice. A little question that popped to mind out of that example though is the other thing about family work or inviting families into individual work is that there'll be a key character who's not at the session. And you're working with a young person's drinking and their mum comes, but the dad's not there. Or you like your example where the actual child themselves isn't there. And it just suddenly made me think, how do you deal with that? Do you just stick with the voices in the room? Do you use really complex reflections to start to kind of bring the voice in a way of that missing person into the room? Or like, what are your thoughts about that? Little curiosity?
- [47:26]
B
Yeah, I have a whole chapter on engaging.
- [47:30]
A
Yes.
- [47:30]
B
And I think. And that's a. That's a big kind of subtopic in that chapter. And. And I've seen clinicians and actually their entirely entire studies, motivational interviewing studies, where I think they. As soon as the client says, no, I don't want to bring my. My family member into this, you know, venture, which was the case in Project Match, the largest US Study on alcoholism. They gave people. They gave people with alcoholism the option of bringing their significant other into the session. And it was a really. And if they said no, they were done. They didn't do anything else. And I'm thinking, well, that's kind of curious, right? So we're kind of erring on the side of autonomy, like when the clock client. So that's one situation the client objects to an important person being in the room. And so there's a way of having a whole motivational interviewing conversation about that, you know, where you're generating change. Talk about that as a potential target behavior, as a potential benefit. So that was something that I was. I was thinking about for kind of getting the. If you. If you're starting with one client and you're trying to expand to other family members, that's. That's one way of doing it is working with. Through who's there in terms of, like, them giving their blessing for the other person if they don't want them there. So that's a scenario that you run into. If you run into a scenario that you were talking about where one person doesn't want to come that may, you know, that may prompt a motivational call with that specific person, you know, to talk about what it might look like or to address their. In using a motivational interviewing style, talk about, you know, what their concerns are about joining the session. And again, you know, thinking about eliciting potential change talk and hearing their concerns about potentially coming to the family meetings.
- [49:52]
A
You mentioned engagement and the chapter that sort of focuses a bit on that. And I think there's another little phrase there, superfluous engagement trap or something. I think what. What it is speaking to is knowing when the time is right to move from a focus on engagement and. And helping the person feel heard and understood or the. The multiple people and. And perhaps moving on to evoking change, talk and ultimately perhaps even planning. And I imagine.
- [50:23]
B
Oops.
- [50:24]
A
I imagine that is a very tricky little balancing act there because there will be different people at different stages of that conversation maybe, too, and how to know when the family is kind of ready for direction and planning, I suppose, and so on. What are your thoughts there?
- [50:50]
B
So, yeah, I coined another term, right. Another trap. Add another trap. You know. You know why this is. This is so my. My. When I was struggling with a little bit of writer's block, my editor called on Bill Miller to deliver an intervention.
- [51:10]
A
Really?
- [51:10]
B
And. And they met with me. They said, doug, what's going on? Like, why are. Why are you behind schedule on writing? And I'm like, I don't know. I don't like. And some of the things that they said to me. So they had an MI conversation with me about writer's block, and it was brilliant, actually. But one of the things I remember from that conversation is we want you to write the book that you were supposed to write. You know, it was just a beautiful, like, example of, like, we want it to be in your voice. We want it to be. And I think I was kind of. I was kind of in a little bit of a block about. About, you know, what I wanted to say. And, you know, them. Them, in retrospect, them. Them giving me that license to. To be a little bit creative or to think about. This was. Was really refreshing and really helped. Helped me get to the finish line with writing the book. But the superfluous engagement trap, it's just lingering too long on the why. Right. Lingering too long on the motivation. Why are we here? Lingering too long on rapport building. And so, you know, I've had, you know, various family members that have sought counseling over the. The years, and. And, you know, they've told me, like, they're nice, but we don't really do anything. So. So I guess there comes a point where it's like, you know, and I think this is a problem. I. I guess I was trying to send a little bit of a message to the MI community that we've. We've erred. You know, we. We maybe spend a little bit too much thinking about, you know, you know, maybe we have a tendency to lean too long into rapport and it is really a timing thing, you know, and it's something that, that, that we've got to be careful about. But I wonder if, you know, we need, we need to have a, somewhere between kind of a premature focus trap and a superfluous engagement trap is this middle ground of like, you know, we're clicking and we've kind of identified that we can work together, that we've got a little bit of a trusting relationship and you know, the families invited the clinician on their problem solving journey and now what is it that we're going to do together to solve these problems? You know, sometimes there needs to be a little substance to that and a little bit of, you know, other, other expertise and suggestions. And I just wonder if people in the MI community are getting a little too worried about providing their clinical expertise or like talking about potential paths that we might take.
- [54:21]
A
Yes. In individual MI there is, there's sort of a, a moment of engagement where we, we sort of feel, ah, okay, the, perhaps the person is engaged now and, and then there's a kind of a, a moment of agreed focus or something and okay, good, that's sort of. Now let's move into evoking and then we start to, to build a sense of the person's motivation and, and okay, now that's, let's move in like, and it's really important and skillful. MI is about being able to bring awareness to the shifts as we move along and obviously shift back into engagement if something goes awry or there's a rupture or something like that. But, and it just sort of, yes, it's kind of with multiple people in the room and families and so on. It's very, it's a very skillful thing to be able to not get too caught in the engagement only, but also to not necessarily jump to planning, I presume, before people are also. So there's an art to it in a way.
- [55:26]
B
Yeah. So you're making me think of something that I did a while ago. So one of my research mentors, he developed a substance use, a comprehensive substance use and mental health assessment. And what they did was they would give somebody like a 30 or 40 minute assessment and then based on their answers, they would generate a, you know, report for clinicians to guide, kind of a referral session with them. And I built a MI module for them. And so one of the things, one of the ways this worked is that, you know, a person taking this assessment would list they had kind of some forced choice options and why, you know, they had a question on how ready are you to change or how important is it for you to make changes in this area. And they also had kind of like some checkbox lists of, you know, what are some of your reasons for wanting to make this change? But it was a structured assessment and so they would do the structured assessment first and then the clinician would use this, you know, this, this kind of auto generated report to try to, and talk through it and talk through with them, you know, kind of what the, what the client wanted to do. So we had this issue with like, oh, what if someone endorses a ton of different reasons? You're looking at those reasons and you're like, and you're, you know, you're thinking, okay, it doesn't seem to make sense for me now in an open ended question to kind of go back and drudge through all your motivation and like, kind of like ask you again in kind of like an open ended kind of free flowing clinical thing. But so what we kind of landed on was with, with people that endorsed a lot of reasons why not start with, you know, wow, you've mentioned a lot of different reasons on your assessment for changing like this and this and this and this. Tell me a little bit more about that. It seems like you're, you're kind of motivated to do this. It was, and maybe we can, maybe that means we should focus our time more on, on, you know, talking through next steps. So it was kind of like.
- [57:54]
A
A.
- [57:55]
B
And if you think about this in, well, at least in the American health care system, you know, there's so much pressure on time that it's hard to do mi in some contexts. So this was kind of a, this, this was a kind of a solution to that compressed time problem. And what, what I liked about that approach, you know, your question was how do we know if we're lingering too long? It's like you wouldn't start at evocation from ground zero when you already have this, this rich assessment data that someone's got all these. Maybe the conversation needs to start in a different place about, you know, and I called it consolidating commitment. Maybe when we have a lot of reasons endorsed, the focus should be on consolidating commitment and still doing the am I thing and like reinforcing all the reasons that they said on their, on their assessment, but maybe not belaboring it. And this kind of goes back to some of the things that I think Bill Miller has been talking about recently is like mis for people who are ambivalent, right? Like the, like the change talk and the full model are really about kind of resolving some resolution of ambivalence. And if people are coming to us with some pretty decent motivation, the engagement pace could possibly move a little bit quicker.
- [59:33]
A
You sort of, I guess mentioning too there that the RS of raws, which is the reflective summary that if you're hearing these reasons and there's several reasons, it's not necessary at that stage maybe to ask what are your reasons. But it might be really great to do a reflective summary of those reasons and just to package them up and offer them back. And then I loved what you said there. Given those reasons, what might be the next step for you sort of thing? It might be very timely to go to planning and ultimately commitment and that sort of thing.
- [60:08]
B
That's essentially what we had. We had, we essentially had a change talk summary built into an auto generated report. And you know, for, for we were assuming an environment where there's remarkable turnover, you know, younger workforce that doesn't, you know, some of the not for profit, some of the, in the US healthcare system and in the substance use system specifically, we have had situations where it's a, it's a young mobile workforce that turns over a lot. So this was one way of addressing that workforce training need.
- [60:54]
A
The last of your little phrases which I loved was motivational send offs I guess and you did actually mentioned earlier about, you know, the endings too are really important and how we, we manage those. You quoted Shakespeare. Parting is such a sweet sorrow, which I thought was very good. Always good to quote Shakespeare. But. Yeah, well, drawing on your own experience and some of the, the theory that you've presented there in the book, what, what does it mean to, to end work with families in a way that still really reinforces I guess the MI spirit and so on.
- [61:32]
B
I think one of the key points when I was thinking about motivational send offs is we never know when this relationship with families is going to end. Families don't come back, they choose not to come back to us. And so I think it's imperative on us, us to, to think about at the end of our sessions with clients what, you know, what can I say to posit to wrap this session up on a positive note, not knowing if they're ever going to come back and see me again. And so that was kind of the perspective that I was thinking. You know, there's in my field and you know, in my field there's there's a lot of, you know, premature exits from, you know, clients choose not to come back, sometimes with no explanation. So I think it's, it's important for us to, to acknowledge that and to leave them with the, the, the best, most warmest atmos. The idea is just to, you know, we talk about the atmosphere of compassion and empathy, the. In motivational interviewing. And so I think. And a really important place for that is at the end of every family session that we have because we don't know if it's going to be our last. Love it.
- [62:58]
A
And, and hope too, I suppose. Bill Miller, as you know, is really. Well, I've had him on the channel and he's talked about his, his latest book on hope and, and yes, every session leaving with, you know, feeling the compassion and sensing that empathy and a sense of hope, I guess too, in terms of the. What next?
- [63:23]
B
Yeah.
- [63:28]
A
So thank you for giving us a rundown of all of that. It left me with lots to think about because, to be honest, throughout our conversation today, I'm reflecting on lots of clients who ultimately I might see a family member or a couple of family members and then also others for whom I think actually maybe that's a good idea to sort of incorporate that. You were humble in the book about, for example, the research and the evidence and so on. What are your thoughts there? I guess just to finish off in terms of, like, what, what excites you maybe about the future of MI with families clinically, but. But maybe also in the research, you know, like, where do, where do you think we. We go with all of that?
- [64:23]
B
Well, I'm hoping to contribute in that area. I've got a, got a study going on in Brazil right now where I'm starting to test out some of the ideas in the book with one of my Brazilian mentee colleagues and my former PhD students. So we don't know if some of these ideas that I've presented on family Change Talk work. I'd love to see a broader kind of perspective on how we count change talk in families and thinking about change a little bit more broadly than just a single target behavior, but thinking about how Change Talk might be able to. Might be able to predict multiple change behaviors within the same family unit. So that, that I think is a really exciting idea. Right. If we can improve the quality of life of multiple people with a, with a single MI session, that would be really exciting.
- [65:31]
A
What a fascinating idea.
- [65:32]
B
Yes.
- [65:33]
A
I mean, it's. What I really appreciate in, in the book is that you've expanded our thinking about mi. You know, like we said before, the expanding it to apply to multiple people, and yes, imagine if it was to have positive outcomes for multiple people in that one or, you know, those few sessions. But also expanded our ideas about some of the well loved and, and well known sort of strategies or skills and so on, and even introduced us to a few new terms, which is good. So, Professor Doug Smith, I really appreciate you speaking with me on Compassion in a T shirt.
- [66:18]
B
Thank you so much for having me. This has been a lot of fun.