30 Jan 2012
Discussing motivational insights for Transition with Stephen Rollnick and Chris Johnstone (in 2006)
I was reminded by this recent piece by Dr Chris Johnstone over at ClimateCodeRed of the meeting that he and I held in June 2006 with Dr Stephen Rollnick. This was back when I was researching the Transition Handbook, and we met for a day to discuss how insights from the psychology of health behaviour change might be helpful when tackling environmental issues like climate change and peak oil. It was fascinating, and I realised as I read Chris’ article that I had never posted the transcript of that conversation here yet. So here it is, slightly dated, but hopefully containing some insights you will find useful (it’s quite long!). My thanks to Chris and Stephen for a fascinating day (nearly 6 years ago!).
Hopkins. Most of the people who write about peak oil come down to saying the only thing that will be an adequate response to it is something on the scale of a war time mobilisation. A lot of people use that phrase – ‘a war time mobilisation’ – to get across the scale of what needs to happen in terms of pulling in all the different agencies, and industry and government and so on, towards this thing. So that question of how we engage communities on a response of that scale is very much what fascinates me and it strikes me that over the last forty years, the approaches environmental organisations have taken just haven’t done it.
I was fumbling around thinking “How will we create the scale of engagement for a problem this big?” when all the tools we’ve had up to this point haven’t been sufficiently effective and won’t get that scale of response. That’s what led me to looking at this whole addiction thing, because whether or not you can say society is addicted to oil, I think you can argue that society is dependant on oil. I found the Stages of Change model particularly interesting because of the insights it gave into why it is that if you go to a whole town and give them leaflets saying they should put solar panels on their roofs, only 2% of them actually do so, and the rest of them just actually won’t shift.
I’m thinking it’s probably not because they don’t care; then with the Motivational Interviewing approach, it struck me that here’s a tool to work with. Ambivalence is a huge problem on a societal scale – why don’t people do stuff? They’ll plan in advance in terms of their children’s financial futures but not in terms of the climate or that kind of thing. As far as I could see it, it had only really been used for individuals and groups, and I’m kind of intrigued. In designing this process we’re going to be starting in September called ‘Transition Town Totnes’, how might we use insights from Motivational Interviewing on a larger scale, and try and address that collective sense of ambivalence?
If you’ve got different stages of change, how do we best work with the people in these different stages? Because, by my understanding, (and I’m only two months and two books in to all of this!), each of them needs handling in very different ways, and with a very different approach. If you just go running in with a ‘one size fits all’ approach, then you might engage one third but the other two thirds are going to be more put off probably. So how do we engage the people at those different stages? How practically might we design approaches that would bring them on board?
Rollnick. I think that was very carefully put because you talk about using insights from Motivational Interviewing – not the somewhat over-simplified notion of ‘I want to apply Motivational Interviewing to a community’, which could be one slightly over-simplified way of looking at it, and could plunge us in to discussion about the viability of an individual method based on empathic listening getting out into the social sphere with all sorts of issues to discuss and struggle to overcome, which I notice during the forum I started engaging with recently with Allan Zuckoff. But you just talked about taking insights – trying to improve our understanding of the way people feel, and what’s the most constructive way of responding to it. So I’m not wriggling with ethical itches, d’you know what I mean? Whereas if you’d said ‘apply Motivational Interviewing to a community’ and ‘do MI on a community’, I’d be wriggling with itches.
Johnstone. What kind of itches?
Rollnick. Ethical itches, conceptual itches, maybe some practical itches, wondering how realistic the whole thing was, but certainly conceptual and ethical itches, of the kind that Alan wrote about in the forum.
Johnstone. What I’m struck by are the different levels of the spirit of Motivational Interviewing and the techniques of Motivational Interviewing. And the spirit of Motivational Interviewing, as I see it, is very much about not doing things on people to manipulate them in a particular way, but it’s somehow about clearing a space for people to be able to look at the complexity of how they feel about an issue.
It’s not just a case of ‘am I for it or am I against it?’ There are often different parts of people…part of them maybe for, part of them maybe against, part of them maybe unsure. When there is that complexity of different parts pulling and pushing in different ways, this can lead people to become stuck. So when you provide a space where people can look at what the pushes and pulls are within them – I find that enormously helpful. What I also find enormously helpful, working say with people with severe alcohol problems, is when you’re in a space where it’s somehow okay to acknowledge that there are attractive things about drinking, you move out of the space of being the judge and the shamer, which tend to really close people down.
And so I think just applying that spirit and stance to environmental issues is a really good transfer, because quite often I see polarities developing, with one group of people saying ‘you should’ and waving a finger, and other people saying, ‘well, why should I? That I’m being asked to give up things that are important to me – I’m being asked to give up aspects of my lifestyle that I find attractive.’ And so the people who are being seen as doing that are seen as somehow takers away of joy. And that polarity is really a polarity that probably exists in all of us. Certainly with me I acknowledge the part of me that is attracted to aspects of the Western lifestyle – I’m quite attracted to various gadgets; they have incredible utility and allow us to do things.
And the same time I look with horror sometimes at the way I see our culture going, when I read information about what’s happening with climate change. So one of the things I really value about Motivational Interviewing is this idea of rather than the interviewer challenging the clients, they are holding a space where the challenge can occur within the client, in acknowledging their own mixed feelings. And the stance is of really respecting their choice – it’s not about trying to get them to do something, but about when you open up a space where they can really look at what they’re doing, they can work out what they want to do themselves, or get clearer about that.
Rollnick. And I don’t think I’ve got anything about MI to add to what Chris just said – it was all beautifully said and I agree with all of it.
Johnstone. Thank you.
Rollnick. Just beautifully put. And trying to walk over a bridge to what you were talking about…we got in to this MI thing because we became disturbed to the extent to which people were being judged and shamed – to use Chris’s language. How problems were being attributed to the people when in the relationship it was quite clear to Bill and I that we were part of that. And since we were the experts and professionals, it’s not our job to pass judgement about lack of motivation in someone else, but to have a look at the way we were communicating in that.
I think that was the big thing for both of us, and we both had different sets of experiences as professionals, and before that in different situations in the addictions treatment field where we thought, ‘For god’s sake, this professionalized shaming and abusing people is not on.’ So our approach has been soft and therapeutic in the way we write, but that’s the passion that’s behind it. One clear bridge that’s over in to your world is shaming on a large scale, so if you make people feel bad they’re less likely to change.
Johnstone. Yes, although I think I would qualify that because one of the strategies in Motivational Interviewing is to develop discrepancy (where someone is aware of a gap between their behaviour and their values) and when you do this you hold a space where people do feel uncomfortable. After a Motivational Interviewing session it’s possible that someone may feel more uncomfortable than they did at the beginning. Perhaps it’s more about how you can hold a space that supports people to rise to the challenge created by that uncomfortable feeling.
I recognize there are different sides to this – one is acknowledging that feelings of discomfort can be motivating. But there was also something William Miller wrote and it’s something like, ‘When you have a discrepancy you can respond in different ways. One is to change your behaviour and another is to change the information.’ So if you’re aware you’re behaving differently from how you’d like to, you can change what you’re doing, or you can also blank out the information that’s telling you you’re out of step with your values. My concern is that this is happening on a larger societal level. Just thinking for example that Exxon-Mobil the oil company has spent millions of dollars funding public relations companies in America to try and block awareness of climate change issues.
This is very similar to what the tobacco industry did. The tobacco industry pumped lots of money into saying that we need more research, that there’s still doubt about this issue, that it’s not something there’s universal agreement around yet. First of all they did that with the evidence showing people smoking were getting ill, and then they did this with the evidence that people around those smoking were getting ill from passive smoking. The tobacco industry specifically targeted key pieces of research that showed the health risks of passive smoking in a way that created the impression of doubt when in fact there was much clearer agreement amongst scientists.
And I see a similar process happening with the climate change issue. Cultivating doubt keeps us collectively in the contemplation stage of change, rather than allowing us to move on to preparation and action. While part of what’s needed here is awareness raising, I also find it useful to think about different levels of change…there’s raising awareness and there’s changing behaviour – but between those two there’s the big area about how we work with attitude shift and motivation shift and that’s really not down to what the information is but what it means to people.
Johnstone. And if the information means, ‘My god, this is really scary and I can’t handle the distress created by this information’, that’s what leads to people shutting down. This also happens in the addictions field…quite often I work alongside people who have to face completely ghastly information, like their children being taken away, or they’ve got advanced liver failure. Sometimes that information by itself is too much to handle and people close down with it. But if you can be alongside them in looking at what’s going on, you can support them in finding their courage to face things. I like the word ‘en-courage’. When you encourage like this, you support people in finding their courage to face the stuff that’s unfaceable. And I think that’s where some of the skills for motivational interviewing can be really helpfully applied.
Hopkins. I did a talk at Schumacher College a while ago and Satish Kumar was there. The talk I do has a little bit at the beginning about peak oil and what it is, but then it’s all about solutions. At the end he said, ‘that was very good, very interesting, but you know, I do have a problem with you using fear to try and motivate people to do stuff.’ It was interesting and it got me thinking about the film The End of Suburbia, which is the classic way people get in to peak oil – have you seen that?
Rollnick. I haven’t seen it, but I’ve seen it referred to.
Hopkins. Okay. For a lot of people…I’ve seen people really, really distressed by it – it’s a very intense film about what the impact of peak oil could be on society. I’ve done lots of public screenings of it and a few times have had to sort of talk people down afterwards. A lot of people go ‘yeah, fantastic!’, but some are quite distressed by it. That sense of what you were just talking about, about breaking the news to people and how you best facilitate that. There was the thing that Chris put me on to – the FRAMES Model – which I’ve used in the dissertation I’m doing as a thing to pull all the different strands together.
The way they talk about it as feedback in there is really good. You’re presenting – rather than trying to terrify anybody – you’re presenting honest, clear feedback. You know, ‘if you carry on drinking another six months you’re finished’, or actually, ‘this is where the world is at’. The difference comes with what happens after this. If you just present that and just sort of walk off and leave them with it, that’s one of the things that closes people down. I saw James Lovelock speak a while ago, presenting a horrendous gloom and doom climate change scenario – ‘we’re all finished, there’s nothing any of you do when we leave this room tonight that can make any difference, humanity is completely finished. We’re just talking about a sustained retreat to the poles’ I think that’s so irresponsible because where can you go with that? You can’t do anything with that. You want to retreat when you hear that, don’t you?
What I very much try and do with my stuff is present feedback in the form of: ‘Here we are, this is peak oil, here are the scenarios, this is like the ghost of Christmas future in a sense, but how about we do this? Actually it could be fantastic! Actually by the end of this process our quality of life could be much better and we could be spending more time with our kids and have a garden full of carrots. It could all be a much better process.’ In that sense I found that FRAMES Model really, really useful as a way of kind of bringing it all together.
Rollnick. So we could be starting to clarify a number of principles of good practice in promoting change in health related issues on a large scale. On the train, I think I was half asleep when I started dreaming, and I started thinking, ‘Well where are there health concerns that affect a whole community?’…I thought about some aboriginal communities I’ve come across in Australia, settlements where everybody is pissed and addicted to alcohol. Just a whole place is riddled with it.
There’s a San Bushman community I know of in the North West Cape that has a similar problem. They happen to both be very socially deprived and devastated, with an explanation in their history, but the way they present right now is everybody sitting around pissed. So they’re communities where there are clear concerns about peoples’ health and not too dissimilar because I’m sure you could articulate concerns about peoples’ health and well-being in this community or the world as a whole. So I’m comfortable with the lack of ethical itches there.
Maybe because I’m working with the brief intervention health care, general hospital world, I’m used to trying to pull out some simple guidelines. There could be principles that come out of what we’re talking about and there are some principles that are coming out. One’s got to do with how you’re handling information, and how you conceptualise the process of informing people.
Johnstone. I’m picking up there are potential side-effects to the way we present information. We can present the same information in three different ways and have three different consequences, and we need to be aware of the potential for overwhelm and close down when giving bad news. If we are aware of that then we can think of information giving as having different phases to it.
Whatever news we hear in our head, it has to be digested down to the heart level to really take effect. Digestion involves exploring the meaning component of information – what does it mean to me? What are the consequences? And there’s a feeling response to that. Information has to be digested at different levels and if we’re aware of that digestion process, then perhaps we may not give quite so much information all at once, but give it in digestible chunks, and pay attention to the digestion process.
Rollnick. The word ‘digestion’ is lovely there. We’ve sort of agreed that hitting people crudely with a whole load of bad news, like that lecture you described, can reinforce shut down a lot of the time. So time and space to digest is needed.
Thinking just about information for a moment – I think another principle we need to get back to is how you deal with discomfort, with people actually feeling it. And it goes beyond information exchange, it’s a deeper process. We need to hit that principle somehow in some constructive way. But just on the information exchange issue – that might be another principle, that it should have to do with exchange rather than dumping. And dumping fearful information doesn’t lead to behaviour change, especially fearful information that makes you feel ashamed or shut down. We know that in health care.
The renal consultant said to me the other day, ‘Steve, we need help with communication training on the ward.’ So I go down and say, ‘What’s the problem?’ He says, ‘They just will not reduce their fluid intake to below a litre a day, and we’ve got the evidence’, because I think they were on dialysis or something… ‘and we actually say to them, look we’ve got the evidence that you’re not restricting your fluid intake. Can you imagine the shaming that’s going on? ‘We’ve got the evidence that you’re not doing this, and they’re just in denial.
We need communication training to get through their denial. And I tell you Steve, shall I give you an example? They’re in such levels of denial – you tell them that if they drink more than that they’re going to die, and guess what happens Steve? They die.’ That’s how bad their denial is, you know, and if you can imagine what I’m thinking – ‘Man! The way you’re handling information giving – it’s not exchange, it’s dumping! It’s all the things that we know are going to close people down.
But what I found very useful, this is 15, 20 years ago, about these drinkers’ check up studies that Bill did, because they were the first publications on MI that were sort of, of an empirical nature – and he puts these ads in the newspaper that say ‘Are you troubled by your drinking?’, and these folk would come in.
And one group got standard feedback – ‘If you don’t do this, then this, then this…’, variation on soft shaming I would have thought, dumping information, you can see lots of things…as opposed to what he described as MI. I’m trying to unpack what was actually going on in the process, and it wasn’t just the empathic listening, which was there. It was making a distinction between information and the interpretation of it. So I picked that up and I’ve been trying to train healthcare practitioners to consider that distinction.
People have often said to me, ‘But hang on, how can you distinguish between facts and their interpretation? What’s a fact?’ And I think that’s potentially pedantic because if you allow some blurred boundaries I still think the distinction’s useful. The job of the practitioner is to present an exchange, present the facts, all the information. And then their task is to elicit the personal interpretation from the person, so that you’re giving them a chance to personally digest, obviously. And then you can take them to an empathic atmosphere and many of the qualities of constructive change that Chris has been talking about can take place. You can pass judgements on how is this person going, – do they need more information? Are they heading for shutdown? And all that…So getting over to the bridge, getting over the bridge to your world, distinguishing between the facts and their interpretation and encouraging people to make the interpretations for themselves, maximises digestion. How’s that? Do you see what I mean?
Johnstone. This is really good because this picks up from what you were saying in terms of how Motivational Interviewing developed where you and Bill were acknowledging the impact of the way you give information. When you’re looking at the phenomenon of resistance, rather than blaming them for being resistant clients who are unmotivated, you’re acknowledging that actually you can influence the degree to which they become resistant. It’s not the whole story, but you are part of a story, and if you’re part of the story, if you can find out what part you can play in that, then you can start doing the opposite of what would create resistance.
I think this is where the ecological movement can really learn – it’s like saying, well actually the way information is presented will have an impact on how resistant people are, and we could be doing things in a way that’s making people more resistant and increasing polarization. If we were to design a campaign that would really turn people off, and if it was to have an opposite effect of what we want, one of the things we would do is present lots of information all at once in a way that was overwhelming, frightening, and then we would blame people for it: ‘This is awful and it’s your fault.’
Rollnick. And you’d mix up information and peoples’ interpretation of it, you’d confuse the two, you’d lump it all together.
Johnstone. Or you’d be even telling people what their interpretation should be rather that finding out what it is.
Rollnick. So you’re kind of saying ‘Here’s a graph that does this – isn’t that scary?’ ‘You should be scared’, or ‘I’m telling you that you are scared’. Yet people react in different ways and sometimes there is a lot of fear, sometimes there is despair, sometimes there’s enormous guilt, but sometimes there isn’t. Sometimes there’s a sense of ‘What’s that got to do with me? I’m probably not going to be around when that’s happening anyway.’ Or that sense of the kind of nihilism of ‘I already know this and I don’t need to be told.’
Johnstone. I remember I did a training session with someone who was working in a hospice, so it was about how to communicate information about peoples’ prognosis with cancer. And he was saying, ‘Well, sometimes people do want to know, but it’s a bit like if you’re overdrawn, you don’t need a letter from your bank manager every day telling you. You need to know that you’re overdrawn and once you’ve clocked that, you don’t need more communications telling you that.’ What you then do with that information – that’s what you need support with.
Rollnick. Right, so ‘Not hitting the message many times’ is another nice bridge, isn’t it?
Hopkins. Because I’ve been teaching permaculture for the last six or seven years and I use a lot of things that came out of an approach from Australia called ‘Teaching Permaculture Creatively’, which uses lots of things from different creative teaching fields and a lot of that is to do with this thing of rather than teaching people something, you get them to show other people how to do it. That actually if someone tells you something, you remember 20% of it, but if they go out and show somebody else practically how to do something, they remember 90% of it.
One of the things I’m planning to do in Totnes is run an evening class – it’ll be a ten week evening class called ‘Skilling up for power down’, and in the penultimate week I’m going to get the people to each write their own twelve steps to breaking their own oil dependency. So they’ll work out their own twelve steps that will be personal to them, their life, and then they’ll come in the last session and they’ll read out their twelve steps of how they’re going to break that dependency. The evening class will run on a continual loop because lots of people want to do it.
When it starts again in January, the group who’ve done the first evening class will then hopefully undertake to help the next class out. They will commit to supporting each other in doing that, so that then when a second evening class gets to that stage of the 9th week, then all those people will come back in and talk about what they did with theirs. So they’ll be passing that down to the next lot and saying, ‘This is where we got to’. So you have that supporting cycle, which could be really interesting I think.
Johnstone. One of the things that can really help is being in a context of engagement and optimism, when you see other people are taking these things on and doing things, but also in a way that involves manageable steps. That’s also what happens in the centre where I work – we have lots of groups, people coming in with alcohol problems, and they see other people making headway. We have a client coffee room and garden area where they can spend time chatting. When you see other people making headway with something, this gives you the idea that you can too. It becomes something where you have a social context that supports the movement of change, which is different from what many people would otherwise experience.
It’s this thing about manageable steps, plotting out pathways of change, that is also important. But I suppose there’s this need to think of two sides of change; one is developing and strengthening the will, and the other is finding and having confidence in the way. And I think with a lot of the environmental issues these two are influencing each other, because if people have the belief that we can’t change the world, these issues are too big – this is the interpretation side really – then what happens is when they get more information about the problem, because they can’t see the way, it just becomes more and more overwhelming.
Rollnick. That’s right. So it’s not just a matter of coming to believe it’s worthwhile changing the world that’s important, but also, as your story illustrates, enhancing a sense of can-do.
Johnstone. Which you’ve written about is in terms of readiness for change being based on both how important the issue is, but also how confident they feel that they can tackle it.
Rollnick. We could talk a wee bit about those concepts and readiness to change.
Hopkins. Yes, that would be very useful.
Rollnick. But we’re talking about information exchange, and I think we’re sort of assuming that there’s a lot of people who feel ambivalent – that’s an insight we can take over to your world, that people feel two ways about it. And I think Chris has described the nub of that very eloquently and how we can be helpful or less so when someone feels that. So peoples’ resistance to change has at least two origins; one inside them – that’s their ambivalence, it’s not got to do with the way you’re speaking to them, they feel that inside them; and then there’s the way they’re dealt with.
So there’s an inter-personal cause of resistance if you like, and there’s an intra-personal origin. And so one way this discussion could go is looking at how do you help people that feel ambivalent? We talked about the inter-personal quite clearly didn’t we? I think we’ve just about cracked the principles of poor and better practice when it comes to information giving in health promotion. Just basic principles here…
Johnstone. What I find so helpful is this distinction between information dumping and information exchange. Information dumping is just a one-way flow and it’s all about broadcast. Information exchange combines broadcast with reception. When you’re broadcasting, you are giving feedback, as in the Frames Model. This involves raising awareness. You throw something out but you also then see how it lands. It is like saying, ‘Well how does that sound to you?’
You’re then looking at what the information means, what the interpretation is, as well as how they’re running with it. If you can see that this person is struggling with that, then that’s not the time to give more information. It’s to look out for times when information is getting stuck in their throat, when they’re finding that difficult. That’s when they need some support in processing that information in a way where it can be digested and they can work with it.
What the distinction between information dumping and information exchange might mean for us is having some principles we could put out in a tentative way, but also inviting a response. For example ‘Well here’s some things we’ve come up with – what do you think?’ And one of them will be: if you have an evening talk or film where you’re giving a lot of disturbing information about what’s happening in our world, that you include in the programme some time for eliciting interpretation from people. Like, okay you’ve just seen this film – what does it mean? We don’t just close the evening and say goodbye at the end in a way that people are left feeling stunned or shocked.
Rollnick. The healthcare equivalent is of group meetings of people who’ve had heart attacks – this is my little world that I work in, right? They have these group meetings in cardiac rehabilitation settings and then use this kind of crude approach, but they give lectures, and people shut down, and people go off, and there’s no digestion time…It’s quite widespread, this idea that people will change if an expert tells them how bad things will be if they don’t.
Johnstone. There is some evidence that advice information say in giving up smoking from GPs and primary care nurses, does have a limited impact, it’s not completely ineffective. But also, it’s not going to work with everybody, and like any intervention it can go wrong and can have side effects.
Rollnick. I’ve been thinking about this. We could talk about that – if you give someone advice, brief information, why is it that some people change? We could talk about that because I’ve been pondering that, and I’ve sort of resolved it –why it’s taken ten or fifteen years to resolve it I don’t understand – but anyway that’s what happened.
Johnstone. I’d really be interested in your resolution.
Rollnick. Well, I spent a lot of time knocking advice giving, and saying hang on, that’s not an effective way of encouraging people to change – here’s a better way, MI. And yet we know that sometimes people just get a little bit of information and they change, and there’s evidence for it as Chris said, you know? So this new book that I’ve been writing with Bill distinguishes between guiding, directing and following, or directing, guiding and following as communication styles. Very simple and…it’s resolved for me because there’s no implication of one style is better than another, which was the mistake I’ve been making – you know like the directing style with brief advice is less effective. Each style has it’s place.
It depends on the circumstances and the context. With behaviour change, the guiding style’s probably the better default for the reasons that Chris has so carefully articulated – encourage, guide. If you’re going to have a default style for behaviour change, it’s probably the better one. But directing and advice giving can work well if it’s personally relevant, well timed and you care – that’s resolution right? I’m sure that might be one of the explanations why brief advice works. But it will work better if it’s personally relevant, well timed and done with caring – those three qualities. You can imagine a GP giving advice to smokers has those three qualities, and the smoker comes out feeling contained, cared about, you know what I mean? It hit the mark because it was well timed…it was relevant to me, it was personally relevant. So that’s how I’ve resolved it. So in this new book I’m paying quite a lot of attention to clarifying what good directing, skilful directing might look like.
The doctor with the good bedside manner probably had the capacity to shift between these styles appropriately, flexibly and humanely, and when it was time to give advice, gave advice. But also was able to follow and listen, and also was able to guide. So I think the idea of a good bedside manner has been written off as ‘Oh, that’s just somebody who’s nice to their patients’, when actually I think there’s probably quite a lot of skilfulness packaged up there.
Johnstone. Again, in terms of crossing the bridge to environmental issues – there are times when it’s really useful to give clear tips on how to address issues, but it’s also looking for that…where you give tips. This ties back to what you were talking about right at the very beginning about not responding the same way to everyone, moving away from a one size fits all mentality. And you mentioned that one thing that would be worth looking at is the danger of over-simplifying the stages of change. Did I get that right?
Rollnick. Yuh, because I think it’s been over-simplified. There could be a dose-type way of thinking about it – in that stage you do that, in that stage you do that, in that stage you do that. I just don’t think life is as simple as that. Typically it’s pre-contemplation: give them information, consciousness raising. Contemplation: they’re ambivalent, give them MI and if they’re in preparation, give them advice about what to do. It’s got some intuitive appeal but it doesn’t hang together clinically for me, because you can find people who are in contemplation for very different reasons. If you think about what you call the will and the way, or why-change and how-change – think about that distinction. The assumption here with the stages of change is that people in pre-contemplation need help with the will, with why-change, that they need all this information.
People at the other end need help with the how, with the way to change. And these poor fuckers in the middle, I don’t know, what do they need? They need MI, right. What is it that they need? They still need help with the why, which is weigh up the pros and cons, that kind of idea. But actually if you take 20 smokers in the contemplation stage and you interview them, you don’t come out with it as clearly as that. You find smokers who are very unready to change who don’t need persuading about the why – it’s the how that they’re hassling with. They’re in pre-contemplation and they’re in shut-down. But it’s not because they lack information, or they need their consciousness raised by some wonderful new insight. They’re in pre-contemplation but they’re in shut-down – they don’t know what the hell to do about it. D’you see what I’m saying?
Johnstone. And presumably people can be in different stages with different issues. You could have a drinker who is in the pre-contemplation stage with his drinking and preparation stage with his smoking and contemplation stage with his relationship with his wife – presumably you can be on different ones.
Rollnick. Spot on.
Johnstone. I find what you’ve just said very helpful – just moving out of the assumption that it’s the why people need when they’re in pre-contemplation, because I see that too. Sometimes people know about the issue, but as soon as they look at it, so much fear comes up that they think ‘My god, I can’t handle that’. What’s lacking here is the capacity to respond meaningfully to the information. And if you can’t respond meaningfully to it, people may think, ‘What’s the point of worrying about something you can’t do anything about? If you can’t do anything about it, then switch it off.’
Rollnick. With that in mind I’ve had folk from different parts of the world who work in deprived environments come to me and say, ‘You know, people need help with the how!’ And of course, the more deprived people are, the more that is the case. If you think about the San Bushmen community, they do need help with the ‘how’, big time. So I don’t see Motivational Interviewing as just residing in the world of the ‘why’ – it’s got as much to do with the ‘why’ as it has to do with the ‘how’. I don’t believe Chris, when he’s with some drinker and struggling with the ‘how’ will say, ‘Well I’ll tell you what to do mate, why don’t you bah, bah, bah…’ It doesn’t work, people don’t change like that. So the style of MI and guiding and encouraging people applies across both the ‘why’ and the ‘how’. And yet I’ve been pigeon holed by the Stages of Change model into apparently defending this idea that MI is for the ambivalent fuckers in the middle and it’s only about the ‘why’. D’you see what I mean? And it’s not like that.
Johnstone. I’m picking two things here – one is Motivational Interviewing as a style, which is about guiding and supporting as opposed to directing. And that style is something you can apply at any stage of change. But also there’s the issue of ambivalence, which I feel is likely to always be there anyway, whatever stage of change. It’s more about the degree to which it’s at the front. I think it’s a useful assumption to have that there’s always likely to be some ambivalence, even if people on the surface appear to be keen, because also motivation is something that can be cultivated and strengthened wherever people are at. If we can give attention to drawing out the ‘why’ then that can strengthen the enthusiasm for change.
Hopkins. So in terms of this idea of using this questionnaire to assess, to get a snapshot of different communities within a town’s readiness to change, do you see there being value to that – what insights would that elicit and what might one do with them if you did that?
Rollnick. I don’t think it’s been done before. So I don’t know. I imagine it’ll be helpful for the very reasons you want to do it, which is you’ll get a photograph of peoples’ different motivational states. But if we think about the limitations of the Stages of Change model, it’s the implications of action for people in different stages we have to be careful of. So I suppose we might find it useful to distinguish between the realm of explanation and the realm of action, okay? This will help you in the realm of explanation in understanding this complex world of where people are at in relation to peak oil. The implications for action might be something quite different and I can think of lots of examples in my work life and personal life where people will assume that you get fixed on an explanation and action follows immediately from it. CBT’s got that quality. Your only problem is we need to do a proper assessment. Once we understand your cognitive distortions, the implications for action are quite obvious.
Hopkins. What’s CBT?
Rollnick. Cognitive Behaviour Therapy – it’s something that’s in our world. And when I was trained as a behavioural psychologist, you know…twenty five plus years ago, the only problem I had was to do a proper functional analysis of your behavioural problems. So to do a proper functional analysis you had to fill out a diary so I could analyse things properly, right? And then when you didn’t bring the diary back, of course I blame you right? You’ve got a motivational problem. But the naïve assumption then was that there’s this realm of explanation, which I’m an expert in and once I know, then the implications for action are obvious. It’s flawed.
So I think with the Stages of Change model, if it helps you understand different motivational things, great, but the implications for action might be something different. Like you could analyse that San Bushmen community and say, ‘All the buggers are ambivalent and addicted and dependant. Therefore they all need MI.’ Actually what they’re doing, some smart lawyers have got alongside them and they’ve sued the South African government for taking their land away – the apartheid government before that and before – and they’re getting new land. And now they own diamond mines right? And now suddenly they’ve become incredibly wealthy and the whole thing’s going to have to get sorted out.
It happens to the aboriginals as well to some extent. So the realm of explanation might be they’re a community of addicted, dependent people; the realm of action’s something completely different. Do you know what I mean? And in our world we have people with multiple inter-related problems, which is a topic we should return to. If I come across somebody who’s sexually abused as a kid – this was my standard client in Primary Care that I used to work with. There was a waiting list full of sexually abused as a kid, single parent, history of abuse and physical violence with partner, partner’s buggered off, two or three kids with behavioural problems, agoraphobic, socially isolated and they need a tipple to get out the house.
So now what problem do you focus on there? Which? They’re all inter-related. Assumptions about what ‘the problem’ is or what the problems are and therefore what you should do about them…you’ve got to be careful with. I ended up working in the social sphere – I didn’t become a specialist in sexual abuse because I felt this was the primary underlying problem and therefore the implications for action as sexual abuse counselling…it’s a very tricky one.
But if you get somebody with diabetes with multiple inter-related things it’s a very tricky decision about where should they start? You don’t necessarily start with the most serious or…you may start with the one that’s easiest but maybe that’s not where they make the most impact. It’s a very tricky challenge. And I ended up devising self-help groups for these agoraphobic women so it was a more community response. So explanation and action aren’t linked. So I think the Stages of Change model would be great for understanding. I think the understanding might be enhanced by looking at the will and the way, or importance and confidence, or ‘why’ and ‘how’, where their motivational struggles might be, how they feel about how important it is and how confident they are to make some changes in line with something that’s healthier. Do you see what I’m saying?
Rollnick. So that might be a different questionnaire Rob and maybe that’s something that you take out of it…if you’re doing a thesis you could’ve looked at that, I was just making a suggestion. But the implications for action I think probably are if the question is good enough you’ll get confused by the data which is a good thing! It’s compatible with what we find on an individual level – it’s not so simple. Whereas if you come out with neat, formulaic things like…there’s usually a third, a third and a third – a third will be pretty good and patient, I can make some changes…I don’t know that the implications for action are necessarily…
Johnstone. What I like about the Stages of Change questionnaire is that it brings a focus on the steps of change that happen before people make the physical change. Often there’s this big focus on have they changed or not, and you’re looking at the end part of the journey when there’s all these steps towards that. If people aren’t making those end changes – like they’re not giving up cars and having solar panels – it’s very easy to feel despondent in the same way that a lot of GPs feel despondent when working with people with alcohol problems. Because even though they’ve been giving all this time they’re still drinking. I think that by applying the stages of change questionnaire a number of times, you can plot movement that happens before the behaviour movement. So if you think of those levels of change of increase in awareness, change in attitude or motivation, and then change in behaviour, there’s changes that happen before the change in behaviour.
Rollnick. It is useful.
Hopkins. Because you come back to it annually in a longitudinal way and assess whether the other things that you’re doing are actually having an effect as well.
Johnstone. In this whole realm of larger change and addressing ecological issues, it brings the focus to the change before the change, which has often been ignored. There’s been this idea that if you give people enough information the action will follow, and that’s clearly not the case.
Rollnick. Yuh. And I think that’s very useful so don’t take my reservations too seriously because the culture we’re living in, everything is action orientated as Chris is implying, and problem solving. And the pre-occupation with targets, assessment procedures and healthcare, and deadlines, appointment times, structures, gets people in to the state of mind where it’s all about action and then directing is the obvious style to use. And I suppose one could build up a critique of health and social care as being all action orientated. Then with regards to the political spheres, there must probably be similar processes going on. And understanding change in a slightly more thoughtful manner is a big leap forward.
Johnstone. As you said, no one has done this before in relation to looking at attitudes about oil use, for example, so just to begin to do it is a step forward. There’s some trial and error whenever you try something new. It’s like saying, ‘Well this is useful in this field, let’s try it in this field’, and you’ll probably become aware of the problems in the application. I think what we saying is, ‘These people have thought a lot about difficult behaviour change, and here we have difficult behaviour change, and let’s see if we can transfer some of the insights, understandings and strategies here and see what happens.’
Rollnick. It’s fantastic, and I’d really like to get right back to the beginning – you used that phrase ‘transfer some of the insights’. You didn’t use the phrase ‘apply MI as technique across the board’.
Stephen Rollnick is Professor of Health Care Communication at Cardiff University and is known internationally for his work developing the motivational interviewing approach. With William Miller, he co-authored the classic text Motivational Interviewing.
Rob Hopkins is the co-founder of Transition Town Totnes and the Transition Network. You can read more about him here.
Chris Johnstone is an addictions specialist working in the UK health service and trains healthcare professionals in motivational interviewing. He also runs workshops aiming to cultivate empowered responses to global issues and is author of the self-help book Find Your Power.