Motivational interviewing and the reframing of identity: small stories in first encounters between clients with alcohol use disorders and their therapists
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Cindie A. Aaen Maagaard
Cindie A. Aaen Maagaard is Associate Professor in the Department of Culture and Language at the University of Southern Denmark. Combining narrative and multimodal approaches, she explores health communication in collaborations with the Health Sciences in several areas, with a focus on the field of Narrative Medicine. She is a senior researcher in a project on sexual health communication funded by the Danish VELUX foundation, and co-coordinator of the teaching program in Narrative Medicine at her university.
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Anette Søgaard Nielsen
Anette Søgaard Nielsen is Professor in the Unit for Psychiatric Research at the Department of Clinical Research, University of Southern Denmark. Her research focuses on alcohol use and dependence, therapy, and motivational interviewing. She has been an expert consultant for the government, and since 2011 she has been chairperson for the organization Alcohol and Society, which works for prevention and treatment of alcohol disorders.
Abstract
This article investigates how the reframing of a client’s identity emerges in talk therapy known as Motivational Interviewing (MI), and discusses the ethical dimensions of the therapist’s role. As a method developed for conversations about behavior change, MI combines a client-centered and a directive approach that emphasizes, and ideally also strengthens, a client’s autonomy and resources for change. One characteristic of MI is the extended use of a therapist’s reflections on a client’s change talk in ways which create a new narrative version that highlights the client’s resources and commitment to change. Using a dataset of three first meetings of clients and therapists, we trace this narrative reframing by employing Bamberg’s three-level method for the analysis of small stories through the story told, the here-and-now interaction, and references to broader cultural master narratives. We show how on all three levels, alternative identities emerge through narratives co-constructed between the client and the therapist, and we discuss the ambiguities of narrative ownership in the delicate balance between client-centeredness and direction in MI.
1 Introduction
For therapists and other health professionals, helping clients to resolve ambivalence towards unhealthy lifestyle behaviors and commit to change is a part of the communicative work of practice (Rollnick et al. 2005). For clients, ambivalence towards changes, despite knowledge of the adverse consequences of certain habits, can be a barrier that is difficult to overcome (Forman and Moyers 2019). Motivational Interviewing (MI) is a method for therapy developed for conversations about behavioral change that combines a client-centered and a directive approach (Carr and Smith 2014; Miller and Rollnick 1991, 2023). It is conceived as a collaborative conversation for strengthening a person’s motivation for and commitment to change (Miller and Rollnick 2023) of, for example, drinking habits, smoking, and exercise.
It is central to the spirit of MI that the autonomy of the client is not only respected, but strengthened (Miller and Rollnick 2023). Since the evocation of motivation and commitment is the aim, a strategy of the MI-therapist is to listen carefully to the utterances of the client and reflect back what the client reveals, with particular focus on change talk, the expression of needs, wishes, reasons, and strategies for change. In such reflections, the therapist elaborates the desire to change and the personal and social resources that might enable this (Lord et al. 2015; Miller and Rollnick 2023). By emphasizing the client’s strengths and agency and by downplaying lapses, doubts, and setbacks, the therapist offers the client a reframed understanding of self, which is developed through the narrative that emerges in the exchanges between the client and the therapist.
Because MI emphasizes client autonomy and agency, it invites an examination of how reframing occurs through the therapist’s work of guiding and directing, and calls for consideration of the ethical dimensions of narration with and for the client. Accordingly, our study analyzes the co-construction of narratives with a focus on where and how the client’s agency is strengthened and how potential barriers are downplayed, particularly through the therapist’s reflections on the client’s narrative. We employ Bamberg’s (1997, 2020) method for the analysis of small stories, which examines the positioning of the client through three “levels” of narrative: within the story that is told, the situation of telling, and the social and cultural narratives that are invoked through and in specific interactions – in this case, the therapy session. As we show, this enables us to trace reframings of the client’s identity and to uncover the tensions between guiding and directing the client. Overall, through a small-story perspective, we aim to illuminate the communicative dynamics and ethical dimensions of narration and ownership in MI and suggest that this approach has explanatory power with respect to how MI works. Our investigation therefore focuses specifically on the processes of narrative co-construction (Bamberg and Georgakopoulou 2008; Schafer 1992) that occur as the therapist cultivates change talk through reflections, i.e., which expressions are made salient in the conversation; how their meanings change as they are transformed by the therapist to take the narrative in certain directions; and the consequences of this process for the identity of the client that is created in the encounter.
In what follows, as part of literature review, we first document the principles and method of MI as well as narrative co-construction. This is followed by a description of the dataset and the analytical framework of small-story analysis. We then present the findings of our analysis of the narratives of three clients – Niklas, Olive, and Clara – in their first meetings with therapists, the aim of which is to motivate the clients to participate in therapy for alcohol use disorder (AUD) among the elderly. Finally, our discussion reflects on our findings, with a focus on the ethical issues raised as therapists offer clients alternative narrative versions of identity.
2 Literature review
2.1 MI as a therapeutic method
MI was developed in the 1990s by psychotherapists Miller and Rollnick as an approach to therapy that combines aspects of two much debated and traditionally separate approaches: (i) a client-centered belief in the client’s potential for self-actualization, and (ii) a directive approach, in which a therapist intervenes in behaviors “in part by managing ways of talking about those behaviors” (Carr and Smith 2014: 84). MI is defined as a “collaborative, person-centered form of guiding to elicit and strengthen motivation for change” (Miller and Rollnick 2009: 137). Accordingly, unlike traditional conceptions of client-centered counseling, it is consciously goal-oriented with intentional direction toward change (Miller and Rollnick 1991, 2023). The “spirit of MI” is based on partnership, compassion, acceptance, and empowerment, as the therapist listens non-judgmentally with empathy and the ability to understand the client’s perspective (Miller and Rollnick 2023). Empathy is viewed as a skill that the therapist can learn, which entails “understanding another’s meaning through the use of reflective listening […] and requires sharp attention to each new client statement and continual generation of hypotheses as to the underlying meaning” (Miller and Rollnick 1991: 20).
In guiding clients, the MI therapist strategically elicits and responds selectively to “change talk” (Miller and Rollnick 2023). Seizing and reflecting on, for example, the client’s expressions of the desire, need or willingness to change, the therapist seeks to increase the client’s strength of expressed motivation for a target behavior change and to diminish defenses of the status quo. The MI-therapist makes use of questions, reflections, affirmations, and summaries. Reflections are characterized as simple (repeating more or less verbatim what the client says) and complex (reflecting a deeper understanding or proposing a hypothesis by going beyond what is explicitly stated by the client). Reflections are key in achieving MI’s combination of client-centered and directive approaches. In their capacity as being client-centered, reflections function to check the therapist’s knowledge about the client and signal both a “lack of definitive or authoritative knowledge about the client’s inner world” and an “interest in accruing that knowledge” (Carr and Smith 2014: 97). In their capacity as being directive, reflections can be formulated in ways which “change the meaning of the client’s statement just enough to prompt the client to elaborate, equivocate, or revise” (Carr and Smith 2014: 98).
2.2 MI and issues of interaction
Carr and Smith (2014: 89) characterize MI’s combination of client-centered and directive principles as “seemingly paradoxical and unprecedented.” Indeed, literature suggests that there are areas in which the boundary between the therapist’s guiding and directing demand careful navigation. During reflections, for example, the therapist may ‘lend’ the client words, particularly those that could suggest change, if she senses that the client is reluctant to broach an issue (Barth and Näsholm 2018). This potentially shifts the source and meanings of words, as well as the balance of influence on the emerging narrative. Additionally, the “practice poetics” of MI – the management of stylistic features including word choice, intonation, turn-taking, and pauses – function, according to Carr and Smith (2014: 85), as a means to “achieve the highly synthetic effect of client-centered directiveness.” For example, pauses allow therapists “to say something in the moments that they say nothing” (p. 106; italics in original), and suggest that therapeutic principles are operationalized not only through content, but also through formal choices in the discourse (Carr and Smith 2014).
Deppermann et al. (2020: 2) point out that there are “sensitive moments in therapy” which involve “psychotherapists’ epistemic authority concerning the client’s current feelings.” In a positioning analysis of psychodynamic therapy sessions, the authors investigate therapists’ shifts in attention from the representational content of clients’ stories to the significance of performative elements of the therapeutic interaction to discover and suggest to the client meanings that the client has not recognized or explicitly verbalized (Deppermann et al. 2020). In this shift, “from the client’s explicit self-positioning to an impression [the therapist] has gained about [the client’s] present emotional and cognitive stance toward his health condition” (p. 8), the therapist enters an interpretive realm that is less certain and more fraught in order to bring new understandings to light for the client’s consideration and the negotiation of acceptance or disagreement.
Like the studies above, we are interested in moments in which the ownership of narrative becomes ambiguous and seemingly dependent on the therapist’s interpretation and management. We find this particularly pertinent for the MI method, which emphasizes client autonomy and takes its point of departure in the client’s self-representation with the aim of motivating change. Narrative is a powerful resource which (re-)frames one’s understanding of self (Bamberg and Georgakopoulou 2008; Bruner 1991; Charon 2006; Eakin 1999) and may suggest a path forward along a particular trajectory.
3 Data and method
3.1 Data
In the present study, we have selected first consultations between clients seeking treatment for alcohol use disorder (AUD) and therapists. During first meetings, a client typically describes the reasons for seeking treatment, and the narratives told often involve the client’s background and significant past events. These narratives may be decisive for a client’s decision to engage in treatment and for compliance (Søgaard Nielsen 2003). The present study is based on selected examples from a corpus of 341 recordings of first encounters between clients and therapists during the Elderly Study, a clinical trial in Denmark (Andersen et al. 2015) aimed at evaluating the effect of treatment for AUD. First encounters were chosen because at that point, the therapist knew little about the client, and the client still had to decide whether to commit to treatment. The participants were aged 60+ and had been diagnosed with AUD. The participants gave informed consent to their conversations being used in research, and the Elderly Study was approved by the local Ethics Committee in Denmark (ID number: S-20130138).
The participants in the Elderly Study were randomized to one of two outpatient treatment courses, both initiated with a first encounter with a therapist, based on MI. All sessions from the study were audio-recorded, and a random sample assessed for fidelity to MI ( Kramer Schmidt et al. 2019). For the present study, the fidelity to MI was assessed as above or close to the recommended threshold values for good MI (Kramer Schmidt et al. 2019).
3.2 Analytical procedure
A random sample of 10 recordings out of the 341 Danish first encounters was transcribed in full and anonymized. The transcriptions were read by both authors to identify instances of reframing and select cases for positioning analysis. Three transcripts were selected as representing the broadest variation in client readiness to change, the reasons for approaching treatment, and the nature of reframing, respectively. The present authors – one of whom is a native English speaker who has worked professionally with translation – contributed to the translation of the transcripts from Danish to English. Effort was made to ensure the idiomatic features of spoken language and fidelity to the style and content of the original.
Close readings were then performed with the aim of understanding in detail the role of the client and the therapist’s reflections as reframing occurred. For our analysis, we employed the approach developed by Bamberg (1997, 2020), as explained below.
3.3 Analytical approach: small-story analysis of positioning
Because “narrating, as a speech activity that makes claims vis-à-vis the who-am-I question, requires the ordering of characters in space and time,” narrative is regarded as a “privileged genre for identity construction,” allowing narrators to seek coherence in life events and reflect on themselves in past times and places (Bamberg 2010: 5). In considering how narrative offers a resource for navigating a sense of self over time, Bamberg and Georgakopoulou (2008) and Bamberg (2010) shift analytical attention from overarching life narratives to “small stories” told in situated interactions. As brief, often open-ended stories and fragments, small stories lack the artfulness and resolution of full-blown narratives, reporting instead on occurrences ranging from close to or remote from the moment of telling (Bamberg and Georgakopoulou 2008). The sharing of small stories plays a role in the constitution of identity as the stories are used purposefully and unfold in a narrative co-construction with others (2008). According to Bamberg, it is not only the referential function of narratives, but also the communicative situation in and for which they are shared, that play a role in identity formation (2010: 5–6).
“Positioning,” a concept central to Bamberg’s method, refers to the discursively constituted “social and emotional stances individuals take towards real or imagined others” (Bamberg 1997). The concern here is for how participants in interactions are aligned in relation to others: the degree to which they share or have differing attitudes, agency, world views, and values. A position is agentive and depends on discursively constitutive possibilities for action, agency or passivity within situations (Davies and Harré 1990). For Bamberg (2010), alignments, non-alignments and their combinations not only reflect, but are also constitutive of, interlocutors’ identities and relations of power as emergent and negotiated.
For the analysis of how narrators are positioned, Bamberg’s (1997, 2020) method approaches small stories from three closely linked vantage points. On level I, the referential meanings of the story are interpreted with a view to what these indicate about the identity of the teller: “how story characters are constructed in position to one another within the specific sequence of narrated events” (Bamberg 2020: 251). The analysis on level II moves to a consideration of the significance of the narrative at level I within the context of telling and aims “to develop an understanding of why the particular story was told at this point in the conversation” (p. 251). Finally, level III attends to how “claims or stances of narrators [go] above and beyond the local conversational situation” (p. 252). This level addresses how, in the construction of content and audience in levels I and II, tellers invoke “dominant discourses (master narratives)” (p. 252), as part of the activity of understanding and making claims about who one is. Thus, this analytical method shows “how the referential world (of what the story is about) is constructed as a function of the interactive engagement, where the way the referential world is put together points to how tellers ‘want to be understood’; or more appropriately, how tellers index a sense of self” (Bamberg 2010: 8, italics in original). With this focus on identity in interaction, Bamberg’s method offers a useful approach to understanding the narrative co-constructions and reframing during MI.
4 Findings
We turn now to the analysis of three clients’ first encounters with their therapists. We begin each case with a brief summary of the client’s situation, then present the analysis of excerpts of the therapy conversation. Pseudonyms are used to protect the identity of the clients and other persons.
4.1 Niklas: “forgive me, I have sinned”
Having reached retirement age, Niklas is a pensioner. In his youth, Niklas was a workman in a factory where drinking was a part of the culture. Now, Niklas has extra time on his hands, with boredom as a result. Niklas “loves” aquavit, called “snaps.” Although he can abstain from drinking for several months, and his social relations subsequently bloom, at times “the rat begins to gnaw,” and Niklas takes up drinking up to two bottles of spirits a day. What matters most to Niklas is his adult daughter and his good relations with his ex-wife. During this consultation, Niklas describes how his daughter got him to seek treatment.
(1)
Niklas: And uh, I suddenly had a lot of time, being a pensioner, you know, and, and, and then you sit around, bored.
Therapist: Yes. So, something happened in your circumstances, something that changed, you got more time on your hands. There was, there was, suddenly no longer your work that called on you every day, and that meant that alcohol could fill more space in your life again.[…]
Niklas: That’s the short version.
Therapist: That’s the short version.
Niklas: Yes.
Therapist: Yes. And, and I’m thinking, you know, about that period you’re telling about here, uh, where you suddenly go from being part of the work force and then all the way to today.
Niklas: Yes.
Therapist: Where you’re also, you think now, now I’ll, now something else needs to happen, now you’ll take part in this project and look at yourself in a different way. [Niklas describes how he has been part of two research projects before, and how another therapist suggested that he consider enrolling in the research project, the Elderly Study. This led to Niklas accepting this first encounter with the current therapist].
Therapist: OK. So, you’re the kind of person who, one who actually is the kind who is very keen on benefitting science, if you like, from the experiences you’ve had.
Niklas: Yes, yes.
Therapist: Like that. And there you were actually thinking that alcohol, it was, it was also something you could be open about and, and also examine a bit more closely, where you stand.
Niklas: Yes.
Viewed through the lens of Bamberg’s model, on level I, that of story, Niklas portrays himself as a person who behaves in response to circumstances around him, not necessarily through deliberate choices. His drinking followed the conventions of the workplace. As retired, he now drinks out of boredom. He seeks treatment prompted by his daughter and participates in the Elderly Study at the prompting of his previous therapist. Taking Niklas’s narrative snippets that portray him as reactive, the therapist, however, unfolds them into explanations (time on his hands made room for drinking, turn 2), imagined thought processes (“you think,” turn 8) and characterizations (“you are keen on benefitting science,” turn 9). Through the therapist’s unfolding, an agent with other qualities begins to emerge, i.e., Niklas who reflects, decides, and desires to contribute.
On level II, the here-and-now interaction, Niklas’s narrative is elicited by the therapist, and Niklas provides it in response, as part of the implicit contract between the therapist (helper) and Niklas (in need of help). The therapist echoes Niklas to show she is listening (“That’s the short version,” turn 4). Yet, as the conversation unfolds and the therapist presents her reframing of Niklas’s stories, it is Niklas who repeatedly acknowledges the therapist’s recasting of him as an active agent, which he confirms verbally (“Yes,” “Yes, yes,” turns 10 and 12).
On level III, that of dominant cultural narratives, Niklas might, on a cursory reading, fit a cultural stereotype of “workman,” first within a culture of masculinity and conformity, and then within a narrative of the “bored” pensioner with nothing to do. In ascribing certain thought processes to Niklas, the therapist offers a counter narrative with a version of identity that entails agency. The therapist reframes Niklas as a reflective and self-examining subject who wants to “look at” himself “more closely” in “a different way” (turns 8 and 11). By shaping a different protagonist, the therapist counters the cultural master-narratives first suggested by Niklas.
(2)
[Niklas describes his drinking habits prior to meeting the therapist.]
Therapist: Yes, yes. And there, and there your body simply gives you the sign that now, now it’s, now it’s had enough after that. And then you go on and do something different again.
Niklas: Uh… I don’t know, uhm, I just choose to say that I get some uh, that I get some moral hangovers.
Therapist: Mmm mmm.
Niklas: Because I feel I’ve let others down.
Therapist: OK. You feel that, that you can’t be who the person you want to be in your life?
Niklas: Uh, yes, I felt that I let some people down.
Therapist: Um. Yes … And there you’re thinking, there, so you’re thinking that it is important for you to, like, deal with and change these things again [Niklas: Yes], that, that you can be the person you want to be, again.
Niklas: Yes.
Therapist: Yes, yes. It sounds as if, so, that you actually reach inside and find the resources to make a change, um, from something that, that is, back to something that you really want to have in your life. That is, freedom for you, yourself, to be the person you want to be.
Niklas. I don’t know if uh … If it should be expressed in, in that way, because I love snaps, I like uh the taste, and then after three or four mornings, you know, uh, then I feel, now I have to taste it, right? [Therapist: Um], and then it’s after these two-three-four days, then the moral hangover comes.
Therapist: Um, yes. So, on the one hand, you like the taste of snaps, and there is something, when you’ve abstained for a while, then there is something that can come and, and, remind you of how good it has been, that taste of snaps.
Niklas: Yes.
Therapist: And on the other hand, then you say, then it goes fast um, where you, that is, the negative things start to add up, and where you can tell that you feel bad about yourself. So, you have to, and, and just also take a look at yourself again [Niklas: Yes, yes] and try something else.
Niklas: And that, that’s what I’ve said, it is that moral hangover that comes.
Therapist: It’s that moral hangover, yes. Yes, yes, yes. So, there are some short periods that you actually use alcohol.
Niklas: Yes, yes, because, that is, when I’ve had those to-three-four days, then I call [the other therapist at the treatment center]
Therapist: Yes, yes. Yes…
Niklas: And then I say to [the other therapist], “I’m up to my neck in shit, I’m coming.”
Therapist. Yes. This is also about you having found a strategy, this saying to yourself, now I need, now something else has to happen. And it’s simply by coming here, by coming to this alcohol unit and just getting, getting the fire put out in that way, and then getting on with what you really want to do.
Niklas: Uh, yes, uh… That’s both right and wrong, what you’re saying.
Therapist: Um.
Niklas: Be- because uh, when, when I’ve had them every other, third, fourth month, then I really miss the snaps like hell.
On level I, Niklas relates a narrative of abstinence and relapses as well as his attempt at seeking the support of therapists at the treatment center. Niklas’s love of snaps leads to drinking, and his trust in the therapists is his way out of it. The small stories that the therapist constructs both reiterate and confirm Niklas’s ability to seek help and to abstain for longer periods. Her reflections downplay the love of snaps that Niklas has highlighted, and simultaneously, as in Excerpt (1), she echoes Niklas’s wording, adopting the term “moral hangover” (turn 15). Additionally, she offers Niklas new versions of his accounts where change is possible; for example, when he foregrounds his love of snaps, she downplays it and throws light on his periods of abstinence.
On level II, Niklas and the therapist negotiate the interpretation of his narrative. Niklas has something at stake on this level, since his narrative is an argument for help at the treatment center (“when I’ve had those two-three-four days, then I call [the other therapist], turn 16).” Through this small story, he presents himself as a weak person seeking redemption for a fall rather than treatment aimed at cure or permanent change. In other words, he is strong and persistent in presenting a narrative about his weakness. Through expressions like “I don’t know” (turns 2 and 10), “say” (turn 2), and “that‘s both right and wrong, what you’re saying” (turn 2), Niklas asserts authority over his story, his language and the motivations he ascribes to his actions. His questioning of the therapist’s narrative becomes a mode of resistance to the potential asymmetry of the positioning of the client and the therapist within the conversation.
At the same time, the therapist exhibits language synchrony to establish affiliation with Niklas when, for example, she adopts Niklas’s expression of a “moral hangover” (turn 15), and when she earlier in their conversation replies “Cheers” when Niklas pauses and says “Cheers.” Such synchrony both reflects and reinforces a mutual attunement that allows room for the therapist to adjust to Niklas’s perspective. Simultaneously, he attunes to the wordings of the therapist, when, for example, in other parts of the conversation the therapist describes Niklas’s social relations, saying “So, it is part of the close network” and Niklas echoes, “Part of the close network, yes.”
Level II is reflected in level III, particularly with respect to the cultural stereotypes of people with alcohol use disorder lacking moral accountability. Niklas questions, corrects, and accepts only parts of the narrative that the therapist is offering to foreground his resources. Niklas’s story is more complex: one strand is patterned on a grand narrative of falling (for the taste of snaps), repenting (a moral hangover), and seeking redemption (granted by therapists). Redemption comes when, fallen, he is “up to his neck in shit,” and contacts the therapist at the clinic. There is thus another strand in the story, a demonstration of self-insight into patterns of behavior in which Niklas portrays himself as a person with a moral compass, aware of having let others down.
4.2 Olive: to buy in or not to buy in?
In the next case, Olive is a middle-aged woman who lives with her daughter. Olive’s alcohol consumption increased from a glass of wine a day to one to two bottles a day. Recently, Olive’s daughter commented on her mother’s alcohol intake and told her that she was drinking too much. Only Olive’s manager, a few colleagues, a friend, and her siblings know that she is seeking treatment. The therapist describes what the treatment institution can offer her.
(3)
Therapist: Yes. What are you thinking right now?
Olive: Well, well, then let me give this a try.
Therapist: Yes… You’re both, kind of a little for it and a little against it.
Olive: Yeess, [Therapist: Yes], I am.
Therapist: What is the worst that can happen if you participate? And get this form of treatment? What would be the worst about that?
Olive: It’s just, primarily, if I don’t get anything out of it myself.
Therapist. Yes, yes. And what would be the best?
Olive: That I can take something from here home with me. [Therapist: Yes] and get some tools, right? That’s just it. That’s just it, what I’d like to have.
Therapist: Yes. So… you’re a little nervous that maybe it’s a bit of a waste of time, and at the same time, you’re thinking, errrm maybe it’s worth giving a chance.
Olive: Yes.
Therapist: Yes… Shall we take the leap?
Olive: Yes, let’s do it.
Therapist: That’s good. And you’re of course, as I said earlier, you can say at any point, this isn’t for me after all.
Olive: Yes.
Therapist: Good. Super that you simply say it from the beginning, Olive. I think so, uh, so we know that we have things straight.
On level I of her story, Olive comes across as a woman who keeps her drinking to herself and is ambivalent towards treatment. She portrays herself as someone whose decision about treatment depends on the prospect of getting something out of it: it might be an option if it offers tools for change. The therapist downplays Olive’s response to the question about the worst that could happen (“you’re a little nervous,” turn 9). In contrast, when the therapist asks about the best thing, she not only reflects Olive’s answer, but subtly amplifies it (“maybe it’s worth giving a chance, ” turn 9). As the therapist then iterates Olive’s right to withdraw at any time and affirms Olive for being straightforward while also lending her new words, she gives Olive a way out, shifting her from ambivalence to control over her decision.
On level II, the decision about engaging in treatment is introduced by the therapist, and like Niklas, Olive provides her account, as part of the implicit contract between the therapist (helper) and herself (in need of help). The co-construction of prospective narratives becomes a negotiation between the two about the very premise of therapy – what it can offer and whether it is worth it. This paves the way for the asymmetry of the therapist and the client to shift to an alliance, as the therapist asks, “(shall we take the leap)?” (turn 11). At the same time, Olive’s autonomy is preserved through reassurances that she can withdraw from treatment at any time.
On level III, Olive might at first glance fit a cultural stereotype of a stigmatized drinker who wants to hide her problem and is ambivalent about seeking help. However, as we see on levels I and II, through the therapist’s version of the small story, Olive’s decision-making is cultivated. The reflections of Olive’s ambivalence reframe her as a determined person who does not engage in activities that are a waste of time. As with Niklas, this therapist also changes the personal narrative of reluctance by recasting the protagonist in ways that challenge the cultural master-narratives first suggested by the client.
(4)
[Olive describes how she said to herself a while ago that the drinking needed to stop.]
Olive: Um, but from there and then to reach that 100% realization, right, where you say, “Now this has got to end,” that takes time, doesn’t it, because you find 117 excuses, you know?
Therapist: You know, there is thing that’s called a circle of change, and I don’t know if you’re familiar with it. Some clever people have drawn it. I can just try to draw it for you here. … We do like this. It looks a little funny. Up here is what’s called the pre-contemplation, that’s where you haven’t really even given a thought to the fact that this is a problem. [Olive: Yes, yes.] One hasn’t even given it a thought. And then it dawns on one, and then it’s called contemplation. Or ambivalence, and that’s right here.
Olive: I can recognize that.
Therapist: Yes, it’s there, where you’re placed on the one side [Olive: Yes.], so one really wants to do some good things for one’s daughter, right, and on the other side, it’s also nice to be able to have a glass of alcohol once in a while, isn’t it? [Olive: Yes, yes.] But at the same time, there is, you know, a sweet daughter there, who I really want to be a good mother for, right?
Olive: Yes.
Therapist: And it’s tough sometimes when the alcohol fills your thoughts.
Olive: Um.
Therapist: That teetering back and forth.
Olive: Yes, yes, exactly.
Therapist: Perfectly normal to feel that way.
Olive: Yes.
Therapist: And that’s how it is with everything one has to change.
Olive: Yes.
Therapist: So, one’s ambivalent at one point, right?
Olive: Yes.
Therapist: On one hand and on the other hand.
Olive: Yes.
Therapist: And then one takes a decision.
Olive: Yes.
Therapist: Now something has to happen. This has to look different, I want to do something about it.
Olive: Um.
Therapist: And then one takes action.
Olive: Yes.
Therapist. Take action. Take action on a decision. You did that, you know, you took a decision, now something different needs to happen And so you’ve come here.
Olive: Yes.[…]
Olive: I’m never going to drink so much again. I just know that. Yes, no, there are probably others who have said the same thing.
Therapist: But you’ve firmly decided that things must be different.[…]
Therapist: You bring some really good qualities with you in this battle with alcohol.
Olive: Yes.
On the level I of small stories, in Excerpt (4) Olive is a woman who has taken time to decide to change her drinking. It was not her own decision at first; she was doubtful when she arrived at the therapy session. The therapist shifts the focus, first by acknowledging, then downplaying and finally discarding the doubt to the point of portraying Olive as having “firmly decided” (turn 27). The therapist also reworks Olive’s narrative of indecision. Placing her in the circle of change suggests that she, like others, will inevitably progress to decision and change. The therapist incorporates Olive’s personal story into this universal narrative, referring to her daughter and ventriloquizing her perspective: “a sweet daughter … who I want to be a good mother for” (turn 4). Olive is recast as decisive, empowered, and a caring mother.
On level II, the therapist becomes the primary narrator of Olive’s story in the shift from indecision to action. For much of the exchange, Olive confirms the therapist’s version of events with a brief “yes” for every stage in the process. She follows the therapist’s lead, recognizes and then steps into the circle of change. We note how the therapist does not allow Olive to downgrade her decision about change. She cuts Olive short, affirms her stubbornness and presents it as a helpful trait that may be a strong resource in what is framed as a “battle” with alcohol (turn 28).
On level III, Olive employs the universal narrative of ambivalence (“there are 117 excuses,” turn 1). However, the therapist positions Olive differently, offering two new versions relating to her identity: that her ambivalence is natural and temporary, and that she is a strong heroine who takes firm decisions. The description of the Stages of Change model (DiClemente and Hughes 1990), into which the therapist inserts singularities from Olive’s life, counters the narrative of doubt, excuses and failure. The fact that she is “like others” (expressed as a generic “one,” turn 2) becomes a resource, and the reassurance that she is “perfectly normal” (turn 10) naturalizes indecision and doubt. Rather than being a hindrance to change, they become integral to it. Olive acknowledges and adopts the master narrative of the female heroine who takes responsibility and acts, when she says that she is “never going to drink so much again” (turn 26).
As with Niklas, a somewhat different protagonist emerges through the therapist’s narrative. In Olive’s case, indecision is transformed to determination, and the co-constructed narrative counters the master narrative about symptomatic drinking first suggested by the client.
4.3 Clara: something was completely off track, and I took action
The last case concerns Clara, an older woman separated from her husband with two adult children. Five years ago, Clara’s alcohol consumption increased from light social drinking to daily drinking alone to wind down after work. Clara describes her turning point, New Year’s Eve, when she realized that she was drunk early in the evening before joining a party.
(5)
Clara: And I go and buy, I think it’s kind of a strong beer, some champagne and a bottle of wine for the host, right? And I drink it before New Year’s Eve and I’m actually drunk when I get there, and that’s what says to me, why am I doing this? Because there’s no reason for that, because we’ve always enjoyed ourselves and we get plenty to drink, and it’s not really that at all, but I say to myself, it’s absolutely and completely wrong.
Therapist: That was simply the drop that made the cup run over, when you found out, there’s something here that’s not right.
Clara: Yes, yet again, because there was an episode before Christmas, right?
Therapist: Okay.
Clara: And the next one happened so fast after that.
Therapist: Yes.
Clara: Where I had actually made the decision and contacted you. So that’s why I’m absolutely convinced I need help.
Therapist: Yes, when something becomes too difficult, you simply choose to act on it and take care of yourself and do something good for yourself. [Clara describes what had happened prior to New Year's Eve. She had been very drunk just before Christmas when her daughters came to visit and was approached by her daughters the next day.]
Clara: And there I was just getting up and putting a rubber band in my hair, and I look like something the cat dragged in.
Therapist: So, it wasn’t the mother they knew or that they know (…).
Clara: But then I sat down and lit some candles, but I hadn’t been as fresh and active, I didn’t look … either, I looked like shit.
Therapist: You haven’t been [Clara: And I felt like it] you haven’t been there for them.
Clara: No, and you could say it may have been my cry for help.
Therapist: Yes, look at me, it’s actually not going quite as it should.
Clara: Yes.
Therapist: So, you have been really good at raising your daughters, so they react when they notice something is wrong.
Clara: They came the next day, didn’t they? Where it was all just so cozy.
Therapist: Yes.
Clara: And we had a great conversation.
Therapist: Yes.
Clara: And I promised them I’d sort it out. So, it was also me who then started to investigate what I could do and what kind of treatment I could get.
On level I of her story, Clara presents herself as a person who decides to seek treatment when it dawns upon her that she has a drinking problem. She positions herself as capable of self-reflection about her actions and insightful about her own self-image. She describes herself being unable to keep up the façade, and acknowledges “it may have been my cry for help” (turn 13). In response, the therapist reflects that “you have been really good at raising your daughters, so they react when they notice something is wrong” (turn 16). The reflection foregrounds Clara as a competent parent, shifting drinking into the background.
Throughout the encounter, the therapist systematically reflects Clara’s statements and adds that she is taking good care of herself. The therapist thus affirms Clara’s ability to act on her decisions. The therapist also reframes help-seeking from a position of completely out of character (“there is something completely wrong,” turn 1) to being a positive act of self-preservation (doing “something good for yourself,” turn 8).
On level II, this narrative is not elicited, but rather adjusted by the therapist. It is noticeable that while Clara is the primary narrator of her story, the therapist slightly, but constantly, emphasizes Clara´s role as protagonist when she introduces small stories that might be signs of her needing help. Each time, Clara continues the road map laid out by the therapist.
On level III concerning the master-narrative, Clara employs the narrative of hitting rock bottom as a first step towards change. The therapist, however, situates her within a narrative of the competent mother who has raised forthright children and thus has the resources needed for a heroine to make changes. As in our two other examples, the reframed identity emerges in a narrative that arises through alternative interpretations of the client’s resources. Here, reframing occurs not by placing a different protagonist in the narrative, but rather by bolstering the strengths that the client as protagonist presents.
5 Discussion and conclusion
The examples of first encounters illustrate three very different interaction patterns between the therapists and the clients although all therapists adhere to the same method, Motivational Interviewing. Niklas presents himself through a story about remorse and redemption, which is changed by the therapist into a story about strength and personal insight. Olive describes her doubts about what treatment can offer, and the therapist offers her a counter-story about autonomy, her ability to make good decisions, and the prospect of entering the circle of change. Clara presents her realization that she is on the wrong track, and the therapist strengthens this insight by casting even more light on her commitment to change. These differences are apparent in the stories that emerge on Bamberg’s (1997, 2020) level I analysis.
On level II, the situated interaction, each encounter involves a help-seeking client meeting a therapist who might or might not be able to offer the help in question. However, the positions of the clients and the therapists differ in the encounters. In the case of Niklas, the reframing offered by the therapist is questioned and adjusted, and thus the positions of the therapist and the client shift throughout the encounter, as authority over the narrative alternates. In the encounter with Olive, a reversal of the positions of the client and the therapist occurs in stages: first Olive has the narrative authority, as she emphasizes expressions of doubt. The therapist meets Olive halfway when she acknowledges Olive’s autonomy. The therapist’s subsequent suggestion that they take the leap together then puts them on equal footing, but the therapist in fact becomes the primary narrator of Olive’s narrative. This contrasts with the positions of the client and the therapist in the encounter with Clara. Here, the positions of authority over the narrative do not change. Rather, the therapist cultivates Clara’s narrative throughout the encounter.
Each of the examples also invokes and relates to larger cultural master narratives. On level III, we see, for example, the almost religious narrative about repenting and seeking forgiveness in Niklas’s case; the universal narrative of processes of change in Olive’s case; and in Clara’s case a classic fairy tale plot in which the heroine recognizes an enemy and decides to fight it.
On all three levels, as identified through Bamberg’s (1997, 2020) model, the discursive reframing of the clients’ identities emerges. Narrating an alcohol problem to a therapist is by no means a solitary process of the client but involves a complex set of activities undertaken by the therapist: listening to the nuances of language, interpreting and attending doubly to the client’s singular story and to universal narrative patterns, selecting paths to pursue and reject, as well as formulating questions and reflections. The therapist not only calls for motivation that already exists (Miller and Rollnick 2023), but also co-constructs, with the client, motivation through a narrative about an active protagonist that even counters internalized master narratives, and in doing so may stimulate a client’s faith in their ability to change. Our narrative perspective helps to explain how resources are foregrounded to reframe the identity of the client, and may also suggest why clients participating in conversations with MI-therapists feel listened to in a non-confrontational manner (Jones et al. 2016).
Bamberg’s (1997, 2020) analytical method also casts light on the problematic ambiguities of narrative ownership that arise in the management of the MI conversation between client centeredness and direction. Ownership, as explained by Shuman (2015: 42), citing the narratologist Volosinov, “describes a relationship between speakers and listeners and between narrative and events; it is ‘territory shared by both addresser and addressee’” (Volosinov 1973 [1929]: 86). Our analysis shows how in this fraught territory, the MI-therapists demonstrate empathy by means of simple reflections and by echoing the clients’ utterances. The therapists accordingly signal acknowledgement of how the clients position themselves. The balance shifts, however, when the therapists, through complex reflections, offer the clients revised narratives with new positions of agency that are on the one hand empowered, but on the other allow the therapists to take the lead in the conversations, that is, to also strengthen their positions in the interaction.
This directive element of therapy is not unusual. As Deppermann et al. (2020: 15) observe, “the rationale of almost every psychotherapy includes to cause psychological change by altering clients’ self-perceptions, self-ascriptions, and understandings of motives and goals by the therapist’s interventions.” Carr and Smith (2014: 88), too, discern directive tendencies in MI therapists’ strategic use of style, such as pauses, the management of which opens spaces for clients to “talk themselves into change.” What our analysis helps explain is how the client’s autonomy and agency that is emphasized in MI is dependent upon the therapist’s position and agency as a co-narrator of a reframed client identity pursuing specific narrative paths.
Our analysis suggests that narrative management occurs in the reframing of the client’s identity, as the therapists’ reflections are incorporated into this reframing. This is visible in language synchrony, in which an interlocutor, whether client or therapist, seizes on and repeats the language of the other; this is a part of the poetics of MI, which blurs distinctions between client-centeredness and direction in the territory shared by clients and therapists as narrators. The therapist’s echo of selected phrases of the client is a stylistic acknowledgement of the client’s perspective (Lord et al. 2015), with the result that it becomes an important theme and a direction in the narrative which the therapist pursues, eschewing others. Similarly, the balance of influence may shift in language through the lending of words (Barth and Näsholm 2018), i.e., by embellishing the story with intentions and thoughts which may or may not be the client’s (“you’re thinking, errrm maybe it’s worth giving a chance,” Olive, turn 9); (“you are keen on benefitting science,” Niklas, turn 10). Similarly, the therapist’s ventriloquizing of the client’s voice (“I have a sweet daughter who I want to be a good mother for, ” Olive, turn 4), is at once a viewing of the world through the client’s perspective and a potential projection onto the client of the therapist’s own imagined response (“sweet”) and ascription of intention to the client. These reflect the movement away from the clients’ identity claims and the therapist’s treading onto more uncertain ground of interpretation, which is characteristic of the interactional, performative level II analysis (Bamberg 2020; Deppermann et al. 2020).
Nonverbal cues also constitute performative meanings, as Deppermann et al. (2020) demonstrate, and this points to a limitation in our analysis. As it was based on a transcribed dataset from a previous study, we are only to a limited extent able to trace the meanings of pauses, emphases, and paralinguistic signals that are part of interactional meanings. Had our analysis included other performative cues, we would have been able to trace in more detail the basis of the therapists’ interpretive moves beyond the clients’ words.
In sum, as our analysis shows, the therapists offer the clients language, interpretations of situations, transformed stories, and revised characterizations, as well as allusions to alternative cultural narratives for the client’s construction of identity. As both clients and therapists narrate and listen, certain aspects of content and language are selected, foregrounded, and pursued over others, enabling the reframing of identity in ways that bolster agency and self-efficacy. At the same time, the narrative that emerges complicates the question of whose story it is, who is telling it, and whose goals it aims to fulfil in the navigation between client-centeredness and a directive approach that is the hallmark of MI.
About the authors
Cindie A. Aaen Maagaard is Associate Professor in the Department of Culture and Language at the University of Southern Denmark. Combining narrative and multimodal approaches, she explores health communication in collaborations with the Health Sciences in several areas, with a focus on the field of Narrative Medicine. She is a senior researcher in a project on sexual health communication funded by the Danish VELUX foundation, and co-coordinator of the teaching program in Narrative Medicine at her university.
Anette Søgaard Nielsen is Professor in the Unit for Psychiatric Research at the Department of Clinical Research, University of Southern Denmark. Her research focuses on alcohol use and dependence, therapy, and motivational interviewing. She has been an expert consultant for the government, and since 2011 she has been chairperson for the organization Alcohol and Society, which works for prevention and treatment of alcohol disorders.
Interview excerpts in the original Danish transcript
P = Patient
T = Therapist
(1)
P1: Og øh, så fik jeg jo lige pludselig tid, det var pensionist ik’ og, og [uhørligt] (…)Og så sidder man og keder sig.
T: Ja. Så der skete noget sådan i dine livsomstændigheder, sådan der ændrede sig, du fik mere tid mellem hænderne, der var, der var pludselig ikke et arbejde, der kaldte sådan på den måde hver dag, og det gjorde at, at alkoholen ku’ gå ind og få en anden plads igen i dit liv.[…]
P1: Det er den korte variation.
T: Det er den korte variation.
P1: Ja.
T: Ja. Og, og jeg tænker jo så på den periode, du fortæller om her, øh øh, hvor du sådan går fra arbejdsmarkedet og så frem til i dag.
P1: Ja
T: Det her med også at du, du tænkte nu, nu vil, nu skal der ske noget andet, nu vil du gå ind i projektet her og også kigge på dig selv på en anden måde.
T: Okay. Så du er sådan en der faktisk sådan øh, går meget op i at der ka’ blive trukket videnskab, om man så må sige ud fra de, de erfaringer du har gjort dig.
P1: Ja, ja.
T: På den måde. Og der tænkte du egentlig også at alkohol det var, det var også noget du også sådan ku’ stå frem omkring og, og, også undersøge lidt nærmere, hvor du selv står sådan.
P1: Ja.
(2)
T: Ja ja. Og der giver, der giver kroppen dig simpelthen signalet om, at nu, nu har, har den fået nok efter det. Og så går du ind og gør noget andet igen.
P1: Øh … Det ved jeg ikke øh, jeg vælger kun at sige at jeg får nogle øh (hoster), at jeg får nogle moralske tømmermænd.
T: Uhm uhm.
P1:Fordi jeg føler jeg svigtede.
T: Okay. Du føler at, at du ikke kan være den du gerne vil være i forhold til dit liv?
P1:Øh ja, jeg følte, at jeg svigter nogle mennesker. Uhm. Ja …
T. Og der tænker du, der, der, der tænker du så, det er vigtigt for dig ligesom at gå ind og ændre igen på det her [P: Ja], som, som, så du igen kan være den, du gerne vil være.
P1: Ja.
T: Ja ja. Det lyder som om, at så, så går du faktisk ind og henter nogle ressourcer frem til at lave en ændring øhm fra noget som, altså tilbage til noget som du, som du rigtig gerne vil ha’ i dit liv. Altså friheden til selv at, at ku’ være den du gerne vil være…
P1: Jeg ved ikke om øhh. Om det skal udtrykkes på, på, på den måde, fordi jeg elsker snaps, jeg kan godt li’ øh smagen, og så kommer der de der øh efter en tre-fire morgener der ik’ [I: Uhm], øh så føler jeg altså, nu skal jeg ind og, og, og så smage den ik’ [I: Uhm], og så er det efter de der to-tre-fire dage så kommer de moralske tømmermænd [uhørligt].
T: Uhm, ja. Så på den ene side så kan du godt li’ smagen af snaps, og der er noget sådan, der, der, når du har været afholdende et stykke tid, så er der noget, der sådan kan komme ind og, og, og sådan minde dig om, hvor, hvor godt det har været i, i nogen, den der smag af snaps og sådan.
P1:Ja.
T: Og på den anden side så siger du, så går det også rigtig hurtigt øhm, hvor at, at det sådan, det negative kommer til at fylde, og hvor at du kan mærke, at du får det skidt med dig selv. Så du bliver nødt til og, og ligesom også og kigge på dig selv igen [K: Ja ja] og prøve noget andet.
P1:Og det, og det er hva’, som jeg har sagt, det er de moralske tømmermænd, der kommer ind.
T: Det er de moralske tømmermænd, ja. Ja, ja ja. Så det er nogle korte perioder, du faktisk går ind og har øh et eller andet alkoholforbrug i.
P1: Ja ja, for altså, når jeg har haft de der to-tre-fire dage, så ringer jeg op til [ANDEN BEHANDLER].
T: Ja ja. Ja …
P1: Og så siger jeg “Jeg står i lort til halsen [ANDEN BEHANDLER], jeg kommer”.
T: Ja. Så det er også noget med, at du har fundet en strategi, det her med at gå ind og sige nu har jeg brug for, at der skal ske noget andet. Og det er simpelthen det at møde op her øh, har været at møde op i alkoholenheden og ligesom få, få brandslukket på den måde, og, og komme videre med det du gerne vil.
P1: Øh ja, øh … Det er både rigtigt og forkert, det du siger.
T: Uhm.
P1: For-, fordi at øh, øh når, når jeg har de der hver anden, tredje, fjerde måned der, så savner jeg sgu virkelig snapsen.
(3)
T: Ja … Hvad tænker du lige nu? …
P2: Jamen, jamen så lad mig prøve altså det der.
T: Ja … Du er både sådan lidt for og imod.
P2: Jaa, (T: Ja) det er jeg.
T: Hvad er det værste, der kan ske ved at deltage? Og, og få den her form for behandling? Hva’, hvad vil være det værste ved det?
P2: Det er sådan øh, helt primært hvis jeg ikke får noget ud af det selv.
T: Ja, ja. Og hvad vil være det bedste?
P2: At jeg kan komme hjem med noget herfra [I: Ja] og få nogle værktøjer ik’ også. Det er da. Det er da det, jeg gerne vil ha’.
T: Ja. Så du er lidt nervøs for, at det måske kan være lidt spild af tid, og samtidig så tænker du, arh det er måske også værd at gi’ en chance.
P2: Ja.
T: Ja . Skal vi springe ud i det?
P2. Ja, lad os gøre det.
T: Det er godt. Og du er jo, som sagt som jeg sagde tidligere, kan jo til enhver tid sige, det er altså ikke mig det her alligevel.
P2: Ja.
T: Godt. Super at du simpelthen lige fik sagt det fra start af, [P2]. Det synes jeg, øh så ved vi, så er der klare linjer.
(4)
P2: Øhm, men så derfra og så til at komme til den der 100 % erkendelse ik’, hvor man siger “Nu skal det være slut”, ej der går altså noget tid ik’, fordi man finder på 117 undskyldninger ik’ også .
T: Der findes jo det, der hedder en forandringscirkel, og jeg ved ikke, om du kender til den. Der er jo nogle kloge mennesker, der har tegnet den. Jeg kan lige prøve at tegne den for dig her. … Vi gør sådan der. Den ser lidt sjov ud. Herop det er det, der hedder førovervejelsen, det er der, hvor man egentlig ikke har skænket, at det her det er et problem. (P2: Ja, ja) Man har ikke skænket det en tanke. Så går det op for en, og så hedder det så overvejelsen. Eller ambivalensen, og det er jo der.
P2: det kan jeg godt genkende.
T: Ja. Det er jo der, hvor man står på den ene side [K: Ja], årh så vil man rigtig gerne gøre nogle gode ting for, for ens datter ik’, og på den anden side så er det jo også rart lige at ku’ få et glas alkohol i ny og næ ik’. (P2 :ja, ja). Men samtidig der står altså en sød pige der, som jeg gerne vil være en god mor for ik’.
P2: Ja.
T: Oh, det kniber nogle gange når alkoholen den fylder og.
P2: Uhm.
T: Den der vippen frem og tilbage.
P2: Ja, ja, netop.
T: Helt normalt at ha’ det sådan.
P2: ja.
T: Og sådan er det jo med alt, man skal forandre på.
P2: jo.
T: Så er man jo på et tidspunkt ambivalent ik’.
P2: jo.
T: På den ene side og på den anden side.
P2: Ja.
T: Så tager man en beslutning.
P2: ja.
T: Nu skal der ske noget. Det her skal se anderledes ud, jeg vil gøre noget ved det.
P2: Uhm.
T: Så handler man.
P2: Ja.
T: Handling. Handler på beslutningen. Det gjorde du jo, du tog jo en beslutning, nu skal der ske noget andet. Og så er du komme herned.
P2: Ja.[…]
P2: Jeg kommer aldrig til at drikke så meget igen. Det ved jeg bare. Ja, ej det er der nok nogen, der har sagt før.
T: Men du er fast besluttet på, at tingene skal se anderledes ud og det jo en [afbrydes][…]
T: Du har nogle rigtig gode egenskaber med dig i forhold til den her kamp mod alkohol.
P2: Ja.
(5)
P3: Og jeg går hen og køber, jeg tror det er sådan en… en stærk øl som champagne og en flask vin til værten ikke også? Og den drikker jeg inden nytårsaften og er faktisk fuld der jeg kommer dertil og det er det, der siger, hvorfor gør jeg det for det er der ingen en grund til, for vi har altid hygget os og vi får nok at drikke og det er slet ikke det der, men der siger jeg til mig selv, nu er det altså rav-ruskende galt.
T: det var simpelthen dråben der fik bægret til at flyde over og der fandt du ud af, der er altså noget her der ikke er hensigtsmæssigt.
P3: ja igen-igen fordi der var jo en episode før jul, ikke også?
T: okay.
P3: og så kom den så hurtigt efter.
T: ja.
P3: hvor jeg faktisk havde taget beslutningen og kontaktet jer. så derfor har, er jeg helt overbevist om at jeg skal have hjælp.
T: ja, du vælger simpelthen når noget bliver for svært at handle på det for og-og passe på dig selv og gøre noget godt for dig selv[…]
P3: og der var jeg bare stået op og sat en elastik i håret og havde ikke noget som helst, så ligner jeg jo røv og nøgler.
T: så det var ikke den mor, som de kendte, eller som de kender.
P3: men så sad jeg og sat nogen lys på, men, men jeg har jo ikke været så frisk og aktiv, jeg har jo heller ikke set, jeg har jo set ud, som jeg havde det af lort.
T: Du har ikke været [P: Og det havde jeg også] du har ikke været nærværende.
P3: nej, og man kan sige, det måske har været mit råb om hjælp.
T: ja, se mig, det kører faktisk ikke helt, som det skal.
P3: ja.
T: så du har nogle piger, der er opdraget rigtigt godt til at råbe højt, når de ser at der er. der er noget, der ikke er som det skal være, ja.
P3: der kom de jo så, dagen efter, ikke? hvor det hele bare var så hyggeligt.
T: Ja.
P3: og vi havde en god samtale.
T: ja.
P3: og jeg lovet dem, at det skulle jeg nok få styr på, så det var jo også mig der så gik i gang med. med at få undersøgt, var jeg kunne og, få af behandling.
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