The Psychiatrist’s Guide to Motivational Interviewing

Abstract

Motivational interviewing (MI) is a technique that can be used to inspire patients who have virtually any level of enthusiasm for change, from almost none to nearly enough, to move toward improvements that can make their life better. The driving goal in MI is to move the patient from a position of complacency to one of more ambivalence about their particular version of toxic habit and then on to a personal desire for change. The approach of MI is one of collaboration in which the psychiatrist seeks to evoke the patient’s own recognition of the desirability of change. The technique of the decisional balance sheet to lay out both sides of a patient’s ambivalence will be exemplified, using alcohol dependence as one example. The stages of treatment are discussed, with associated interventions that reflect the patients’ locations in their journeys toward change.

Introduction

All of us have had struggles in our lives and at least an intermittent desire to better ourselves, to change a habit, or to try something new. All of us have set goals, likely made a few New Year’s resolutions, or determined to do something consistently, like write a journal article for example, only to leave our good intentions somewhere back there in the dust after a few weeks or months.

Congratulations! This means that you can have the empathy and sense of kindred humanity it takes to help patients suffering from substance abuse disorders or other types of “bad” habits with their quandaries. You will learn to have a manner that can motivate them to make the decision that it is worth it for them to once again, or perhaps for the first time, put out the effort to make and sustain a change. It may be a change we would very much like to select for them, but in fact a change that only they can determine to do. In this article, we will describe the concept of motivational interviewing and give some case-based examples of how the techniques can be incorporated into psychotherapy with substance abuse and dual diagnosis or other patients in order to help them overcome their addictions or make other desired changes.

What is Motivational Interviewing?

Motivational interviewing (MI) is a technique developed by psychologists Rollnick and Miller,¹ which can be used to inspire patients who have any level of enthusiasm for change, including the all-too-often-encountered absolute-zero enthusiasm, to move toward an important change that could make their lives better. In Ohio, the Clinical Center of Excellence for Integrated Dual Diagnosis Treatment (IDDT) offers opportunities to learn this technique in a seminar.² For those living elsewhere, help is available via the Motivational Interviewing Network of Trainers (MINT)³ and on the Motivational Interviewing website.³

In addition to the need for constant empathic human-to-human connection with the patient, or client in the case of a non-physician practitioner, the driving goal in MI is to move the patient from complacency toward more ambivalence about their particular version of toxic habit. Yes, more ambivalence. You may wonder how this can be therapeutic. The fact is that someone who is not yet contemplating a change is really quite satisfied with the status quo and is thus stuck. He or she is fully immersed in the payoff of continuing his or her habit. Your job, should you choose to accept it, is to move the patient out of this complacency into a more uncomfortable spot where he or she can begin to feel within himself or herself a personal desire for change. This desire for change should be that of the patient and NOT that of the therapist, the court, the case manager, the alcohol and drug counselor, or the parent or spouse of the patient. That is, motivational interviewing is patient-driven, but therapist-enabled.

My first foray into the world of motivating someone to quit an unfortunate habit was in the fourth grade. At the time, my father was an avid enthusiast of Lucky Strike cigarettes. My place at the dinner table was directly beside him, and I would crouch low at the table and attempt to use the napkin holder as a smoke barrier. That having failed to effect a change, I would use various other subtle and not-so-subtle means of indicating the unpleasant effects of his habit on those around him, such as the universal sign for choking. One day my father came home and announced he was quitting cigarettes. I fantasized that my efforts had paid off. He told me in no uncertain terms that it had nothing to do with me, but was because a coworker had told him how much better he would feel. This scenario brings up an important point. Motivational interviewing is not likely to bring “credit” for change back to the psychiatrist. The whole idea is that the patient himself or herself gets the idea in his or her mind to quit and may see the decision as very much having to do with factors outside the confines of therapy. The metaphor of an ice-pick, gradually chipping away at factors that promote resistance to change, is a useful one. The final chip that inspires the change may occur far outside the confines of the office encounter–or the dinner table. In the case of Mr. P from my original article,⁴ he had already heard numerous arguments about quitting from his family and physicians. He needed to receive validation that the decision was entirely his to make as well as assistance to recognize a primary motivator in his life, his granddaughter, to finally prompt him to stop smoking.

There are many applications of MI, and it is a useful skill for a psychiatrist’s armamentarium. It can be used in complement to other types of therapy, including medication management.⁵ Any time a patient is in turmoil with a decision or struggling to meet his or her personal goals for change, MI may provide effective assistance. This can include every-day decisions, such as whether or not to regularly take his or her medications or to try to lose weight, or potentially catastrophic decisions, such as whether to continue abusing drugs or whether to continue a life-sustaining treatment.

Case Presentation 1

Dr. W was a psychiatry resident who underwent psychotherapy, which was recommended as part of her development to become a psychotherapist herself. As many physicians do, she occasionally struggled with her obsessive-compulsive traits, although mostly these were manifested as a professional conscientiousness. At one point in therapy, she began to struggle with a decision about whether or not she should continue to meet with pharmaceutical representatives.

• Resident: Do you see drug reps?

• Psychiatrist: I’m curious about why you’d like to know that.

• Resident: The whole issue has really been bugging me lately. The department no longer allows free lunches, and one of the staff at my community psychiatry sites won’t even talk to them! Am I doing something wrong by listening to what they have to say?

• Psychiatrist: (using reflective listening) You’re beginning to feel uneasy about something you have always taken for granted.

• Resident: Yeah! Even the state psychiatric physicians association is having discussions on the topic.⁶ All of a sudden, I think I might be unethical or something, and I’ve always towed the line and done the right thing.

• Psychiatrist: You feel distressed that you may be acting in a way that does not meet up to expectations.

• Resident: Well, some people seem to think that if you talk to reps you are going to be under their influence to prescribe their medications.

• Psychiatrist: What do you think about that?

• Resident: I don’t know what to think…I guess I can see their point, but I don’t really think that would influence me…but I do know about subliminal messages…but on the other hand, what about all the samples we can give to patients with no medical coverage?

• Psychiatrist: I can see this is a dilemma for you that jars your concept of self a bit. Would you be interested in looking together at the pros and cons of changing your current status of seeing the representatives?

Practice Point

A decisional balance sheet⁷ can be helpful in laying out both sides of the patient’s ambivalence about making a decision. In this example, the treating psychiatrist may have a strong opinion about the best outcome for the resident, but MI is all about getting the recipient to a place where he or she makes his or her own decision about change. The change he or she decides to make may be in a direction or by a means the psychiatrist might not even recommend. In any case, Dr. W’s decisional balance sheet might look something like Table 1.

TABLE 1.

Psychiatry resident’s decisional balance sheet

REASONS TO CONTINUE TO SEE PHARMACEUTICAL REPRESENTATIVES		REASONS TO STOP SEEING PHARMACEUTICAL REPRESENTATIVES
Benefits	Costs	Benefits	Costs
Learn information about new medications	The information may be skewed in favor of their product.	Can be more confident the information I get about new drugs is balanced	Will have to research for an unbiased source of information
Get free samples for my indigent patients	I really hate it when they quiz me	Will not be tempted to start patients on the more expensive new medications without trying something with more years of clinical use first	No free samples
Get free meals with continuing medical education courses	A patient might be put on a medicine only because the samples are available. There might be a better choice for him or her.	Will not be getting subliminal messages to use their products	Will feel uneasy about explaining to them why I don’t want to see them
Free pens and sticky pads	This is money that could be better spent on research and development.	Patients will not think I’m under the influence of the drug companies	Will have to explain my choice to the support staff who like the pens and donuts they bring
Might receive an honorarium or even a free trip if I lecture for them	Patients will see advertising and wonder about it.		No nice meals at places I would not ordinarily eat when I go to the APA
	I would probably need to only talk about information flattering to their company.

In this situation, where the patient is an intelligent and highly motivated person familiar with ethical precepts, this could be the end of the treating psychiatrist’s work with her on this topic. Treatment might resume with a look at why this issue presented such an uncomfortable dilemma for her, although that would no longer be motivational interviewing, and that’s acceptable. Sometimes MI is used in conjunction with other types of treatment, as we will explore next.

Case Presentation 2

Mr. L had been in treatment for bipolar I disorder with medication management and supportive therapy for many years. He had a remote history of alcohol dependence but was in sustained full remission. One day, the psychiatrist was notified that Mr. L was in the intensive care unit with a toxic lithium level. He had been seen in the emergency room the preceding evening and was noted to have a very high blood alcohol level. Fortunately, Mr. L recovered medically and was seen in follow-up as an outpatient. As was the psychiatrist’s usual habit, the patient was asked about his alcohol use.

• Patient: I am so damn sick of you doctors always blaming everything on my drinking!

• Psychiatrist: (reflective listening.) You’re pretty angry about the idea that I think you were only hospitalized because you had been drinking.

• Patient: You better believe it! I am a man! I can have a few drinks if I want to!

• Psychiatrist: (empathy) You want to be respected even when you are drinking.

• Patient: I have had some trouble in the past with drinking but that is not now. I can quit if I want to! Compared to what I used to drink, this is nothing.

• Psychiatrist: (coming alongside the resistance)⁸ So you see yourself as having had problems in the past, but that the drinking you’ve done recently is not harmful for you.

• Patient: Well…I did end up in the hospital…

• Psychiatrist: Tell me more about what happened.

• Patient: I was pretty angry after an argument with my girlfriend and I just decided to buy a bottle of whiskey.

• Psychiatrist: (open-ended question) And then?

• Patient: Well I meant to have a couple of shots, but I guess I drank the whole fifth. I really don’t remember what happened next. They said I nearly died.

• Psychiatrist: (summarizing)⁹ So after many years of not drinking, you decided to have a couple of drinks after the argument with your girlfriend, but unintentionally drank enough to have a blackout and nearly die.

• Patient: I guess that sounds like I do have a bit of a problem…but I don’t want anyone else telling me whether or not I can drink!

• Psychiatrist: (emphasizing personal choice and control)¹⁰ You are a grown man and it truly is your decision whether to drink or not.

• Patient: You better believe it.

• Psychiatrist: I believe it.

• Patient: Well, maybe I should knock off the booze for awhile, at least until you get my medicines adjusted again.

Practice Point

The approach of motivational interviewing is one of collaboration in which the therapist seeks to evoke the patient’s own recognition of the desirability of change. The patient’s perspective on the situation is honored, as well as his or her autonomy. It operates from the assumption that the patient is responsible for finding the means within himself or herself to make the necessary adjustments (albeit with assistance.) It specifically avoids anything that smacks of coercion and is not confrontational or authoritarian.¹⁰

Years before, when Mr. L first decided to stop drinking alcohol, he had presented a decisional balance sheet, which was used to motivate him to make the change for sobriety (Table 2). It is not uncommon for individuals who have made life changes to have lapses or even full relapses into their old pathologic behavior. The same approaches will still apply: respect for the individual, empathy for his or her struggle, and a trust that the strength and personal knowledge needed for a change is present within the individual. So how does one help move someone further along the path to change once he or she has looked into the face of the serious consequences, but feels the strong draws to keep the status quo?

TABLE 2.

Mr. L’s decisional balance sheet

REASONS TO CONTINUE DRINKING		REASONS TO STOP OR CUT BACK ON DRINKING
Benefits	Costs	Benefits	Costs
I like it.	My girlfriend may leave me.	I might feel better (not really sure about this).	Will lose all my good drinking buddies
I feel more relaxed.	Doctor will not consider giving me Klonopin (clonazepam) unless I’m sober.	My girlfriend wouldn’t hassle me.	I’ll be too nervous to socialize.
All of my friends drink.	My boss is beginning to realize I’m coming to work hung over	I’ll keep my job.	My father will mock me until I give in to drink with him.
Everyone in my family drinks.	People tell me I do really Stupid and risky things that I can’t remember doing.	It will be easier for the doctor to control my bipolar.	I won’t feel like a man.
Gives me something to do

To answer this, an important point to keep in mind is what motivational interviewing is not. It is not cajoling, coercing, or demanding. It is not like the fantasy of a colleague of mine, to take an incorrigible patient by the shoulders and yell, “Don’t you see how crazy you are acting?” Just as with adolescents you may know or live with, lecturing and threatening generally only further increase their reluctance to move in the direction of their wise parents.¹¹ When an individual with whom you have poured out your best efforts has had a relapse or made a very poor choice, it can be quite tempting to do one or more of these “no-nos.” The impulse is to let patients know one way or another just how frustrated you are with them and their behavior. Don’t.

But what do you do to move the individual who already knows the pros and cons of changing and is contemplating it, perhaps for the tenth time? How can you help them to make it stick? Just as there are stages of change,¹² there are corresponding stages of treatment, with associated interventions that reflect where the patient is in their journey toward change.¹³ Although patients may go back and forth in their readiness, the basic trajectory of MI is to move patients toward seeing the discrepancy between their current behavior and the personal goals they have for their life. By avoiding moralizing, as well as the no-nos noted in the preceding paragraph, the individual is freed up to see the need for change himself or herself. The potential means by which to do this are protean. The basic stance is to be curious with the patient about the impact of the target behavior on various aspects of their lives, including the entire gamut of the bio-psycho-socio-spiritual realm. Together you peruse their values and their goals and stack them up against the previously elucidated negative impacts. More curiosity on your part allows the patient to gradually have the light dawn. When resistance is encountered, it is not directly opposed, but rather, re-framed or even sided with, so that it becomes the patient who is the one arguing for change. You communicate your belief in his or her capacity to take the necessary steps. This in turn helps the individual to believe that change is actually possible, even for him or her. Once that is established, you can get ready to move from the MI stages of engagement and persuasion into active treatment and relapse prevention, which are not the focus of this article.

Hopefully this taste of motivational interviewing has whet your appetite for more. If so, be sure to check out the text¹ or catch a course. Even if not formally doing MI, I’m sure you will find yourself using the techniques frequently in your day-to-day work. Perhaps even with those adolescents at home!