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The Power of Choice

Posted on July 18, 2014

In several books I’ve read over the last few years, I’ve come across a study involving choice.  It was conducted in a retirement home, where residents on one floor were used for the experimental group and residents on a different floor were used as a control group.  The experimental group was given three additional choices in their environment such as to have a water their own plants – In reality, most of these choices were available to them all along – they were just reminded that they had them.
What was the impact of these newly perceived small choices?  Over a relatively short period of time, the death rate of the control group was twice that of the experimental group.  That’s right – just a few small choices decreased the death rate by half, and significantly increased many other social and health indicators as well. 
Why is choice so important?  When we have a choice, we have power, even if the choice is between several options that all have negative aspects.  When we have options, the processing of the situation remains in the logical part of our brain (specifically the prefrontal cortex).  When we feel a loss of control, our brain will view the situation as a potential threat, and it shifts processing to the emotional and survival brain areas for processing including the amygdala).  The sense of feeling “out of control” oftentimes arises from a limited set of choices.
Many of our clients live in a world of scarcity, and the fewer resources they have, the fewer options are available to them.  The same could be said for many of the systems of care these clients enter.  If they are lucky enough to live in resource-rich areas, they might have several options, but for the most part clients are lucky if they have a choice in where they get their medical care, case management, housing, and food assistance.  Even in high resource areas (usually in large cities), choices can be limited by transportation, stigma, past history with providers, and lack of knowledge. 
Once clients do find their way into our services, choices can remain limited.  Due to scarcity in our systems, there is a great deal of “you must do this to get this” or “you can’t get that here, you have to go across town to get that resource.”  It seems that too often, those in financial, medical, emotional, and psychological need are seen as not worthy of the same choices those with more resources are given.  It is as if we give those with the fewest amount of resources one path to salvation, with huge consequences if they step off that path even for a moment. 
Research also shows that we can limit their choices as well (though likely unintentionally in most situations).  Those in the social service profession have our favorite referrals that have worked well in the past.  It doesn’t take more than one bad experience with a provider for us to cross them off the list of options we’ll give future clients.  Even if multiple resources exist, we can limit choices we provide our clients due to one or two bad experiences.  Many of us (myself included) would rather not give a client an option at all than give them an honest explanation of our (or our clients’) past experiences and biases against that provider.
Reality is that, even if Yelp tells me that the sushi across town is better than the sushi a block away, the fact that I have a choice empowers me and gives me more ownership of the outcome (choosing convenience over quality).  In doing a great deal of quality assessment work around patient/client satisfaction, I know that every place is both loved and hated by different people based on their unique experiences, with the majority falling somewhere in the middle.  The question we need to ask is whether it is better to be honest with our clients and give them our experience (good, bad, and ugly) in a professional manner, or to limit their options based on our experience?  I will admit this is not an easy challenge.
If we internalize the spirit of Motivational Interviewing (MI), especially the Acceptance and Partneringaspects, we are challenged to treat clients as consumers with a choice.  Sometime this choice can seem hidden or limited by resources, but they do have a choice in every situation.  It often falls on our shoulders to make sure they see the autonomy that does exist.  Sometimes we have to think hard about the choices ourselves, and the options might not feel great, but the important thing is to show that the client is the one with the choice and that they are not forced into one specific action.
A client might not choose to take medication that could save their life, might not stop using substances even though it means their kids will be taken away, or they might not disclose to a sexual partner they have a dangerous sexually transmitted infection.  We might not like these choices, as we care about the health of our clients and our communities However, change will happen more often when we reflect back the choices they have and are making, rather than if we judge or confront the behavior. 
“If you keep using crack, you’ll never get your kids back” triggers the amygdala response, whereas, “It seems you have several options. First, you can continue as is and risk the consequences you mentioned; we could look into some treatment options that could help you get your kids back; or we could talk about the other issues you brought up earlier…where would you like to start?” keeps the client in the thinking part of their brain. They have a choice in the next step.
Giving clients options puts the responsibility on their shoulder for the next step. Confrontation makes the problem worse, and brings forth resistance to change.  Change happens when we support and show the client that they have the power of choice.  When we provide choices (the MI concept Menu of Options suggests we give at least three), we put forth the issues but give the power to the client.  Having the client state that they want to talk about treatment options leads to a more logical conversation than a lecture or confrontation. 

Once again, our jobs are incredibly difficult, as we must find options in environments with powerful structural limitations.  My challenge for you this week is to pay attention to the choices, or lack of them, you provide your clients.  When you feel yourself giving only the next step on the limited path, see if you can bring in a few more options along with the one you want the client to take.  It is a small adjustment for most that can lead to big results.  At the very least, you’ll be empowering clients that are too often stigmatized, disenfranchised, and feel they are trapped in lives without choice and power.

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