Larry the Smoker
Larry: I know smoking is bad for me. I know I should quit.
Helper: Then why don’t you? (Righting Reflex Response – Not a MI response)
Possible MI Responses
Permission: “May I tell you what concerns me about your continuing to smoke?”
Evoking: “You are certainly right about smoking being bad for you. Tell me more
about that.”
Double-Sided Reflection: “Earlier you told me that you have a goal of reducing your risk of stroke and heart attack. On the other hand smoking increases those risks. What are your thoughts about that?”
Rolling with Resistance: “It has been hard to quit smoking even though you are concerned about its impact on your health.”
Maria, Mother of 4 year old with Asthma
Your team is seeing a 4 year old boy Larry with poorly controlled asthma in clinic. He has been admitted three times in the hospital in the past 6 months for acute exacerbations. During your interview with the mother, Maria a pack of cigarettes falls from her coat. She quickly states that she does not smoke “around her son.”
Maria says she has been feeling very stressed recently, especially with her Larry’s recent hospitalizations. She has been smoking since she was a teenager (she is in her mid-20’s) and she says that smoking relaxes her. She does think that quitting would help her child’s asthma, and several people have told her that she should stop smoking in the interest of her child’s health. When asked about quitting, she frowns and says she has tried to quit smoking several times in the past without success.
We then use a scales with Maria to assess as well as cultivateconfidence or importance is the use of scales. Hopefully the scales can help Maria to verbalize and process her ambivalence further. In this case, “On a scale of 1 to 10, how important do you think it is for you to quit smoking?” (Maria says 9 out of 10).
“On a scale of 1 to 10, how confident are you that you can quit smoking?” (Maria says 4 out of 10)
So, now do we use Affirmations: recognizing Maria’s strengths and countering a defeatist attitude: “Why did you give yourself a 4 instead of a 2?”
“I am impressed that you have been trying to quit despite all the stress you are going through”
We also use reflecting the pros and cons: “So, it is important for you to smoke in order to deal with the stress in your life, but you also wish you could quit in the interest of your child’s health”
We look Maria driven strengths: “What would make you go up to a 6 or 7?”
We then continue to get more history: Maria, who is 35 years old, smokes with her girlfriends who come and visit her in her apartment. She feels a sense of community with them, and smoking is a shared pastime they enjoy.
Maria does not think her child Larry’s asthma has worsened because of her smoking: “I’ve been smoking since he was born and his asthma wasn’t this bad before”
When asked about quitting, she says: “Yes, I’m sure it would be better for my health, but so would moving out of New York City!”
Maria is then asked on a scale of 1 to 10: “How important do you think quitting smoking is for your child?” (Maria says 3 out of 10)
“How important is it for your own health?” (Maria says 4 out of 10)
We then begin reflecting and empathizing with the “pros” and “cons:” “It seems that smoking is an important social activity for you, but you also would like to quit because it would be better for your health.”
“Yes, New York City can certainly be hazardous to your health!”
We then Roll with Maria’s Resistance: “Yes, it does seem that you’ve been smoking for quite some time and your child’s asthma has only recently been flaring up.”
Emphasize the significance of this Maria’s level on this: “Why did you give it a 3 and not a 1?”
Gladys Mother of 7 year old Susanna with Asthma
Your team is seeing a 7 year old girl Susanna, with poorly controlled asthma in your clinic. She has been coughing 1 to 2 times a week at nighttime, interfering with her sleep. Gladys her mother is rightly concerned and would like some treatment. You prescribe an inhaled corticosteroid for twice daily use to be continued even when her symptoms resolve.
Four weeks later, during a follow-up visit, the Gladys tells you that she stopped the inhaled steroid medication because her Susanna’s symptoms resolved. How would you proceed at this point?
Find out where the Gladys is at: “What do you remember about the instructions for the medication prescribed for your daughter’s cough?”
“Do you have any concerns about the medication?”
“Are there people you know who have taken steroids for asthma?”
“Tell me what you feel [or know] about steroids”
You get more history: Gladys does remember that she was instructed to continue the medication even after Susanna’s cough resolved, but she stopped giving the medication because she “doesn’t like giving medications” to her daughter. When asked why, she simply repeats herself “I just don’t like it!”
All right…what’s going on here? Your are right: Resistance!
In motivational interviewing philosophy, resistance is elicited when we try to push clients farther than they are ready to go.. Resistance also occurs when clients have not been given sufficient opportunity to direct their actions and have simply been given instructions from their helpers.
How do you deal with Gladys’ resistance?
Empathize with the client: “It sounds like many of us have been telling you what you should do and we’re not listening to what you would like to do for your child”
Empower the client: “You know, it’s up to you what you would like to do with your daughter’s medication – after all, you are her mother.”
