An episode of “Changing the Conversation” podcast
Kristin Dempsey and host Ali Hall continue the discussion about macro Motivational Interviewing and share ways to address systemic and structural issues as well as individual issues when supporting change.
January 9, 2023
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Ali Hall, Host (00:05): Hello and welcome to Changing the Conversation. I’m your host today, Ali Hall, joining you from San Francisco, California. I’m a member of the Motivational Interviewing Network of Trainers or MINT, and a full-time MI trainer and consultant, as well as a MINT certified trainer. Our topic today is applications in macro motivational interviewing, or macro MI, and my guest today is Kristin Dempsey, a member also of the MINT, full-time faculty at the Wright Institute in Berkeley, California, lecturing faculty at San Francisco State, and a therapist in private practice. She’s calling in today also from San Francisco, California. Kristin, thanks for joining today.
Kristin Dempsey, Guest (00:51): Thank you so much, Ali. It’s always an honor to be here.
Ali (00:54): Yeah, this is really exciting. Macro MI, definitely a lively topic. I’m glad we’re going to get into it a little bit. Because after all, we know that the strengths and limitations of the traditional motivational interviewing approach, we know that MI has an extraordinary evidence base helping people navigate difficult changes of all kinds. Very few evidence-based practices can really stand on that kind of ground. Am I singular in this way?
(01:27): We also know that from the most improbable of circumstances, people make extraordinary changes when we talk with them in a heartset and mindset of partnership and acceptance and compassion, recognizing the empowerment that people bring, evoking their strengths and wishes and hopes and dreams and desires, and helping them speak a path towards change. I mean, that’s very clear. MI is also most powerful with those who have experienced the most marginalization.
(01:57): Here though, we do run into some challenges because there are some things in fact that are not under individual control at all times, certain behavior changes we might influence as individuals, and yet there may be some things that are a little bit out of our reach. There are some times that systems expect individuals to solve challenges that are structurally or socially engineered. And that might be a role for macro MI. But what do you think about all this, Kristin?
Kristin (02:26): Motivational interviewing is such a powerful tool and it comes in such a way that allows people to be so well engaged and from the place of where they’re willing to start, from the place where they’re willing to come to have the conversation. It’s such a great engagement strategy, and it helps people get focused. And that’s really empowering to get focused. And yet here’s kind of the rub, we have this idea of how to have a conversation about change using MI. I’m doing it and I’m feeling great, but there’s a lot of things out there that individually I don’t have control over. And that’s where the challenge comes in.
(03:03): Here’s the beauty, I think, about motivational interviewing. When we think about it from this macro perspective and the conversation you’re having with David Avruch about how do we start to think about individual responses to systemic issues? One of the things I like to think about when having this conversation about change with someone individually is how do I help someone shift from an individual perspective to be maybe a bit more collectivistic in some ways? In that individually, if I’m thinking about a change target using MI, that’s going to be really hard for me to think about how am I ever possibly going to make a change in the system?
(03:44): I see there’s a big problem say with housing or with the climate or with my individual rights, and yet individually I don’t feel empowered to do anything besides maybe complain or talk about it, which is certainly a helpful thing to do. But what if we started to have conversations in which we were able to help folks think about individually, yeah, probably not going to be able to do much, but individually, I can join a movement. Movements are what makes change. Having that kind of approach of how do we help folks see the door opening into joining up with other folks, being part of a community, because communities are where we start to feel empowered.
(04:26): I think that’s a place where motivational interviewing in this macro format can be really, really very useful. We can be using a lot of the same tools, the same interventions, some of the same structure, but we can help people maybe come to the door of change maybe with a little bit different expectation and a little bit different strategy.
Ali (04:47): Thanks for that, Kristin. What I’m hearing is individual choices and behavior targets are perfect for things that are in our control. One thing I’ve heard you say in different settings is a lot of things are out of our control. While we can’t change a system, we can be part of a movement. You’ve already mentioned environmental concerns, environmental justice, social justice concerns that folks may have, that there are structures that are in place that actually inhibit an individual’s ability to have more control. How do we help people access this other way of being, joining up with a movement without really putting the burden on the individual?
(05:31): I mean, yes, there is that, and yet without burdening individuals who have been most oppressed and most afflicted by social and structural trauma to then become the core of the solution. It’s socially and structurally engineered, and yet we are placing some invitation at the individual’s foot to say, “How can you take up this challenge and how might you be part of a larger movement?” Yes, there’s a balance in there. I’m wondering where from your perspective is macro MI most suitable? What are some examples, kinds of conversations, for example, that really lend themselves to this kind of consideration?
Kristin (06:14): First of all, just go back to something you just said that I’d like to underline because I do think it’s so important. The real gift that MI I think brings to the conversation is this very person driven kind of approach and really empowering people and who’s sitting in front of me. I like to think about it and teach about it in such a way where when I’m working with someone using MI or really anything, but definitely when I’m getting started with MI, I am coming from a position of what I call constant assessment. I’m constantly assessing like what does this person need now, and that really shifts.
(06:48): This idea of there might be individual interventions, like a psychoeducation type thing that’s really beneficial for this person just because they just need some skills for managing life right now as an individual, and there’s this idea of socio education to move into the more collective piece. There can be this dance back and forth, this kind of dialectical approach, if you will, about balance around how much and when and what dosage of individual intervention might I do versus more of the collectivistic or macro based intervention. I think that’s an important thing to be aware of, that it takes some of that real attentiveness.
(07:29): And then the types of things, there’s so many things systemically that folks that we work with are challenged with. There are definitely issues around say like body autonomy, my identity, my safety, my ability to control my body and what I do with my body and who I love and who I care for. So many issues right now around people feeling empowered to have their voice being heard. There is a recent APA, American Psychological Association, survey that came out in the fall, and it’s something like 79% of adults report that they do not feel like people in the government care about them. Folks are feeling just really alienated, and I think that certainly impacts anxiety and depression.
(08:09): Then there’s certain day-to-day life things that people are really struggling with, whether that’s making enough of a living wage to survive on, whether that’s having proper housing or having enough housing, for instance, having access to education, managing issues around discrimination and prejudice and injustice. Just the day-to-day impacts of that.
(08:30): There’s also issues too in the family around rights of families to get what they need to take care of themselves, especially around, as I mentioned, education, but also healthcare and also within families, how are people empowered to take care of themselves and how are people and families able to be aware of places where they may need to have more boundaries or supports if there’s situations like violence and such. There are probably many other issues, but these are some that I tend to see a bit in my work and discuss a lot in my teaching.
Ali (09:01): Excellent. I’m curious if maybe we can dive into some specifics, the kinds of conversations. Let’s say for example that an individual might be suffering and may feel alone in this, and yet there is a structural or socially engineered element to it that is certainly impacting their suffering, but that they might be able to leverage in a change way as well. For example, you mentioned environmental justice and a lot of different social justice issues. You mentioned housing. Let’s say someone is experiencing something that could be viewed as a medical issue, like they have allergies or they’re reacting badly to environmental toxins.
(09:50): A person could be tempted to look at that as well, “I’ve got to go get an inhaler, or I’ve got to go get your medication, or I’ve got to go see a clinic and access healthcare resources that way.” And yet there is this other cause that’s socially and structurally in place. Maybe where the person lives, for example, it is full of toxin or maybe the building the person lives in, their surrounding community is impacted by environmental issues that go far beyond an individual’s ability to take care of themselves medically, but it’s impacting their entire community and neighborhood.
(10:25): I’m wondering how would we shift a conversation like that from an individual responsibility to be adherent with allergy medication and shift it into a social justice and environmental impact kind of conversation? How would we do something like that?
Kristin (10:43): Yeah, I’m thinking just off the top of my head with the example that you gave just to stay at the level where they’re at and do some reflective listening. I’m hearing that you’re really thinking about the things that you need to do to take care of yourself, and that you’re following up and you’re trying to do what you can to get access to care because that’s an issue just in of itself sometimes or many times is even for folks who are completely willing to adhere to medical requirements or medical advice, I should say, just having access to care is another piece sometimes of the social justice issue.
(11:19): But let’s say this person does have access, and then I might just do some reflective listening, just kind of listen to how they’re doing with that and maybe even affirm the fact that they’re taking care of themselves and noticing with them how they’re really stepping up to manage their health. And then I might start to pivot and say, “I’m noticing all these things and I wonder what else you think is going on in terms of maybe the root causes of some of these challenges for yourself?
(11:45): Because I’m hearing that you’re really working hard and I imagine this might be such a challenge to have to keep dealing with this allergy, or whatever it might be, even though you are doing absolutely everything you can on your end,” and just see if I can start to pivot into some discussion of the larger issue. They may or may not have some insight into that. If I start to have a sense that this could be a really good place for me maybe to offer some of that larger insight around maybe some of the larger structural issues like poor housing or environmental pollution or whatever it might be, I would then certainly ask permission.
(12:23): I say, “I’ve been having some thoughts about this as we’re talking, and I wonder if it would be okay with you if I shared those,” just to see if that might be a way of being able to have some beginning conversation. Because I want to be really respectful of people’s boundaries and always be collaborative and find a way to have this conversation as true to the MI format and working with them in that particular way where it’s always this constant process of exploration with curiosity and trying to keep it really conversational, but to help engage folks in that. I find that when I make those types of pivots, many people are more than happy to have that conversation.
(13:02): Many times people feel really validated because there can be a place of, hey, let’s look at root cause and within root cause also think about places where you can be empowered. It doesn’t mean that someone is not being responsible or accountable for taking care of themselves if we look at the root cause. It’s like both of these things are occurring at the same time. I think that can be very helpful because we’re looking at the larger picture. It can be more empowering, and it can also just be more honest.
Ali (13:30): Yeah, thank you for that, Kristin. I’m hearing that there are often overlapping structural concerns that a person could address. Just even in that example, a person could talk with us about healthcare access. They could talk about the environmental justice issue. They could talk about housing. They could talk about where in the community that they have the availability to live. They could talk about transportation. There are many different things I think that would impact the person’s freedom and autonomy to really come up with a solution that makes sense to them in a larger way beyond individual responsibility.
(14:07): Affordability of medications, I mean, I can just imagine so many different structures that intersect as we talk about this. There is this idea too, a humility that I’m hearing as you speak about it because we may have some studied ideas about the person’s experience or structures that are in place, and yet the person’s experience of all that, their expertise in the situation is really at the center.
(14:34): I hear asking permission, inviting a discussion about larger social or structural issues that are impacting the person’s health and well-being with a fair dose of cultural humility to really take the person’s experience as it is as a starting place, their willingness, their knowledge and their expertise, and openness and curiosity that we have to learning about the other’s experience and not just coming in from a studied point of view.
Kristin (15:03): Yeah, absolutely, that’s right. Something to add to this idea of humility is also a perspective I like to take in as well, which is the conversation and helping people engage in these conversations and the exploration, that’s really powerful and that’s healing. Even the smallest steps toward some of this aspect of collective action or consciousness raising or awareness, it starts to transform folks.
(15:35): One of the things I also like to encourage us to think about, and we talk about this in the acceptance commitment therapy community as well, which is don’t wait until you feel better to do things that are collective action or that you value. Sometimes people will say, “Yeah, I’ll get around to maybe getting involved in something in the community when I start to feel better,” or we may even think that as providers. It’s how important it is to really be thinking about, well, wait, that actually could help us feel better if we start to get involved. It’s like don’t wait around to feel better because we might not.
(16:10): Actually the being involved and the becoming more aware and more conscious, that actually is what helps us heal and to be able to hold both of those pieces as we’re also being aware of the fact that we have to be very thoughtful about the pacing, because the pacing can be so different for everyone and it will be different for everyone. Some folks will really be able to step right in to some sort of collective action. Some people, that may take years.
(16:37): And also I’m just very attuned to the fact that if people try out something, maybe they try to get involved in something but they feel badly because they don’t feel like they can be involved enough, I try to be really thoughtful with folks about not trying to help them feel over responsible or feeling ashamed if they don’t feel like they’ve done enough. To be really aware that the awareness and the being part of a community, it takes time, it takes time to build. Every movement, every thought, every conversation is part of this building process. It’s all great. I reinforce everything that anyone does to create more connection because it’s all important.
Ali (17:14): You just mentioned shame. I think David Avruch, who was previously on Changing the Conversation Podcast, I’ve heard him speak about the function of primary emotions, so joy and anger and all these things, sadness. I mean, these are things that have a very maybe obvious function. Shame maybe a little bit less so. When I’ve heard him speak about it, it’s really quite clear that it’s a way to function to keep structures in place. If the person who is experiencing shame and let’s say somebody who has encountered sexual or some other kind of violence, we often hear the person who has experienced the violence as having shame.
(18:02): And yet we don’t always hear about the person having perpetrated that violence as having that same level of shame or any at all for that matter. His idea really when I heard him speak recently was that shame really reinforces social structures. It reinforces power dominance. If the person who has experienced a structural violence or personal violence, then holds their head down and says nothing and internalizes responsibility for that and stays in line, the structures stay in line as well. It may feel like the safest course and certainly no one is second guessing a person’s approach to it, but it is something that keeps things in place.
(18:45): Shame maybe an area where we can really be compassionate with someone and also help them find ways to connect to their own empowerment to decide how much of this is being imposed on me and how much can I do something about in this situation. What feels safe to do? How can I challenge this structure in a way that feels meaningful to me?
Kristin (19:06): I think helping folks understand that emotions are meaningful and sometimes it takes some time for us to figure out exactly what they mean, but they often do serve functions. Again, if there is a sense sometimes of shame coming up, sometimes people have been victimized, I think sometimes the function of shame is there because that helps us think that maybe there was something I could have controlled in the situation and I didn’t. Now I’m experiencing this. But to be able to just be able to acknowledge it as a normal response to things and to provide options for different opportunities, different ways to participate is really powerful.
(19:50): I like too what David was talking about in the podcast about us especially as educators, finding ways for people to use these tools, because students are really excited about learning about the macro issues going on, but sometimes it can be very hard for them to be like, “Well what do I do?” That’s an important piece and responsibility that we have as educators to figure out. What are some tools that we have to help folks actually intervene in this area?
Ali (20:17): I just wanted to share an example too. In my own neighborhood, we have a number of quite a community of vehicle residents. In this community, one of the things that I have seen happening organically is that different vehicle residents have gotten together. They have found a place that they can challenge parking restrictions, which are ways to keep people out of vehicle residency. They found a way to do that. They found a way to collectivize to bring food, to bring educational resources, to even bring a power source to help some of their vehicles manage and get heat and things and run during the day.
(20:59): They’ve also managed to keep themselves safe from being towed, so their homes are not being towed and damaged all the time. It’s something that I don’t necessarily think that there was a motivational conversation that happened with that, but a natural group that forms were able to challenge some very deliberate and also unintentionally effective social structures that disrupt vehicle residency, that destroy people’s homes by being towed all the time, and has created a bit of a safe island for folks.
(21:35): I mean, it’s possibly a unique situation and a unique set of solutions, but there is this hope that people by gathering together for their own social justice and others can really make a big impact. I know that you’ve been working with your students on a particular activity, which I’ve heard you describe as a power wheel activity. I’m wondering if you could say a little bit about that.
Kristin (21:59): The power wheel activity I did with some students who were in a class with me around family violence prevention is what we call it. Early in the class we started to talk about the differences in power and control in the culture, in patriarchy, how it shows up in families and in communities. You might be familiar with the Duluth Model power wheels that were developed in I think the 1980s. Since the 1980s when I first saw them, they have all kinds of varieties of power wheels and they’ve been able to really adapt them to different communities, which is wonderful because it’s been really culturally responsive.
(22:38): The wheel will talk about different levels of power and control in particular family situations and larger cultural issues. I won’t go into describe them, but I will put them in the show notes so people can see all the different power wheels. But the exercise I wanted to tell you about is I had students break up and do a teach back. I had a group of 20 students come into groups of four or five and they will each have a different type of power wheel that they discuss amongst themselves. And that way they learn from each other like, what does this mean? How would I explain it? How do I understand this?
(23:11): We have to think these through, and they’re fairly complicated to think about how you might actually explain and talk about this. And then I reassign the students so they’re all mixed up. And in them mixing up, they teach back to each other the different power wheels like, “This is my power wheel and this is how it might mean.” They would also enact how they are doing this in a way that not just like they’re talking to the students, but then how they might say it to someone they’re working with as a therapist. They’re actually practicing how to explain power and control to individuals.
(23:44): Generally, the power wheel, we’d have these in courses and they’ve been around for decades, as I said, and you maybe potentially hand it to a client, let’s say, someone who’s seeking help, and that might help educate them. But in this particular way, the students are being more active. They’re going into it and actually talking with each other about how they might understand this material and preparing to have a conversation with someone about power and control in the therapeutic setting. In that way, they’re actually practicing the skills, like deliberate practice of how to do this.
(24:16): I got some feedback from students and some students were like, “I can think about doing this almost like in a speed dating way where folks are coming in and we’re actually being able to have a group discussion where each person’s maybe giving little pieces of this or someone’s coming in briefly getting little bits of this,” which I like because there’s an aspect of getting small parts of information at a time so people can take it in. Another student was talking about really appreciating doing the exercise because they could see how other people presented the information, and that helped them think about their own skills and grow their skills.
(24:52): In that particular way, it was really fun to be able to do something that was very empowering for the students to be able to start thinking about, “Yeah, this is how I might actually do this, to have this very intentional, deliberate practice around this macro type skillset.”
Ali (25:06): I love that, Kristin, and I’m sure your students find it really valuable. It feels like this is very akin to an educational approach that’s very much in your wheelhouse. It makes me think that many of us who come to the helping professions have had experiences in our lives with collective action, maybe even a comfort for it. It really might be a natural fit to the kinds of conversations that we have with folks or our students. I’m wondering if that’s been the case for you too.
Kristin (25:36): It has, and I have a history of working in many social justice movements, including things like reproductive rights and antiwar work. Where it came from really was from growing up. I grew up in Northern California and probably the first thing I became aware of, and I was just thinking of this the other day when I was thinking about whales because I was reading about whale watching, is when I was probably about 10 years old in Mendocino County, we had a Save the Whales kind of movement, which has become a funny little tagline in some particular ways. But it was a really important movement because at the time the great whale was almost extinct, and now it’s not.
(26:16): It’s not totally back the way it was before being fished out, but definitely it’s a growing population. You see that. If you were to drive up to where I grew up, one thing you wouldn’t see is you wouldn’t see a nuclear power plant up there, because that was another movement that I grew up with. It was anti-nuke movement that they were able to keep nuclear power plants out of the community. You’d also notice if you were to drive up there that there aren’t oil wells out in the waters, because that was another issue that was also a movement in the community to make sure that we didn’t have oil drilling off the coast of that particular part of California.
(26:52): Being in these various movements, very young, being exposed to them very young really helps you develop a sense of we fight, we win. We may have to keep fighting and we may have to fight over and over in different situations. As we know, as all things we’ve been fighting for, that we have to continue to fight for, but it changes your mindset. It changes who you are, and it gives you the sense of empowerment, quite frankly, and what a community can do when really challenged and when we come together.
Ali (27:24): Thanks for that, Kristin. Its just further evidence that as helpers, none of our experiences are ever wasted. They all end up contributing to who we are. Thank you for that. I am curious about how macro MI might reduce strain for both the person being served and the helper. Provider burnout is a really big deal and it could be that this macro MI reduces some of the moral distress that providers feel. What do you think about that?
Kristin (28:01): Well, I think it’s really key. Again, it’s why we were trying to teach this to students because we want them to be able to have skills and things they can actually do to feel effective in the therapy situation. Even though we’ve been teaching for generations now, like systemic issues that are impacting the well-being of our clients, our families, of the individuals that we see, this actually does something about this. It actually allows us to have some skillsets and to have conversations where we’re addressing the root cause.
(28:38): Again, to have this point of view of it’s not for the individual by themselves to somehow resolve all this, but it’s to help them really shift their mindset to being part of a community. And that in of itself is super protective. It’s super protective for the therapist, also for the people that we’re serving to make this shift from we don’t have to solve everything all the time. A big part of motivational interviewing is not about fixing people, it’s about helping to empower people. This actually allows us to do that.
Ali (29:06): Great. Thank you, Kristin. There really is something in it for all of us and a wonderful exploration. We’re really just getting started with macro MI, and I’m eager to see all of the places that it could be helpful and to start seeing some of those greater outcomes as we continue to work with people who really need support from helpers so much and helpers who need new ways of being with people. Kristin Dempsey, thank you so much for joining us today and for all you do in making the world a better place.
Kristin (29:37): Thank you so much, Ali. It was my pleasure. I love this conversation, and I look forward to having more conversations about the potential of macro MI to really help transform our world. Thank you so much.
Ali (29:48): And to our listeners, join us next time on Changing the Conversation.
Erika Simon, Producer (29:52): Visit c4innovates.com and follow us on Twitter, Facebook, LinkedIn, and YouTube for more resources to grow your impact. Thank you for joining us. This episode was produced by Erika Simon and Christina Murphy. Our theme song was written and performed by Peter Hanlon. Join us next time on Changing the Conversation.
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