MOTIVATIONAL INTERVIEWING (MI) IN EVERY DAY CLINICAL PRACTICE
4rd DAY OF SOCIEDAD MURCIA DE PSIQUIATRÍA (MURCIA PSYCHIATRY SOCIETY)
Col. De Médicos de Murcia (Murcia Medical College) 21/02/2014
I usually use motivational interviewing (MI) as a key tool in order to success in the everyday challenge of treating my clients and patients at the psychiatry surgery. Even more, without meaning I have come to use it as a communication tool with everybody else around me.
We health care professionals all use some motivational style intuitively. Nearly all of us mean to get our patients by empathy: this is the only way to understand their discomfort or suffering and the real reasons why they go to a mental health professional. Often these reasons could seem a rather superficial or banal at first sight. Some other times it is not even the patient, but their family, GP or somebody else who seeks professional advice.
I am well aware that our heavy workloads rarely allow us the time we would like to spend on each patient so we have to hurry up a little. However, I have always preferred “more haste, less speed” because, if we become too strict with the time we spend, we may end up as mere prescription-delivery machines focusing just on the symptoms and ignoring their roots. If we content ourselves with that, we will never help our patient’s initial problem but also we may contribute to aggravate it to chronic. The outermost symptoms are usually be the tip of the iceberg that torments or worries our patients, and we shouldn’t forget that the patient can usually be smarter than we first thought so he or she is likely to decide that he or she is not going to give a monkey’s about our professional opinion, hence the high rates of non-compliance with the prescribed treatment.
As I was saying, we all intuitively use MI in our daily work. I still feel a wave of nostalgia when remembering my time as a foundation doctor. My colleagues and my supervisors, some of them here today, used to tell me, in a humorous and friendly way, that I was slow when attending to patients, that I was able to spend up to two hours with a suicidal girl at dawn after an endless day on call at the A&E department. They would ironically ask me if I was treating them with intensive psychotherapy, when the usual way was the House-M.D. style of telling them off, prompting them not to do it again and inviting them to try to become the centre of attention of their relatives or partners by less ‘messy’ ways instead of being carried to hospital for pills that wouldn’t ever harm them or for some skin-level scratches on their wrists. Still now, despite the 20 years past by and despite the dullness of their cases, I still devote a lot of time to those toying with the idea of mid-night suicide. I must be a bit of a masochistic, but every time I’m called to the A&E department, regardless of how sound asleep I might be or how much of a nuisance the case might be, I usually spend quite a long time with the patient.
Let me please tell a story. I remember when on call some years ago a doctor called me at 3 am. He told me on the phone to go down to street because a “mad woman” was threatening everybody to kill herself. I first put myself together (I’d been sleeping for 2 hours) and off I went down to the street. When I got there, I found a tall strong cross-dressed bloke with nails, lips and eyes crudely done eyes and mascara smearing down his cheeks due to the tears poured over the last hours. His appearance was gloom, his voice barely found its way out of his body and fatigue made him involuntarily cut down the effeminate manners he'd always been proud of when feeling larger than life. I invited him in a polite and engaging way to tell me the reason for needing our help at the A&E department, and, despite his initial hesitation, he told me of his dramatic life meticulously and releasing every now and then some sob:
‘I’m 47 -to be honest, I thought he was much older-, my name is Roberto; however, I prefer Roberta, y’know, after Roberta Flack, that buxom black singer, oh I love her so much. I came out when I was 18, you can imagine, my dad made such a big fuss the night I told him, a convinced male-chauvinist and fascist, he nearly kicked me out home the old bastard, calling me perv and lazy -in fact, he was right about that last one because I was completely unconcerned about my studies at that time and because he had seen some pompous dresses badly-hidden in my wardrobe. Lucky me, mum -mums… y’know…- managed to calm him down and I could stay at home for two years more. I got a job as a kitchen helper in a nearby town but, skilful as nobody else, after six months I took on cooking, and I was bloody good at it. It’s been 24 years now I’m a cook, 24 years me gosh! 24 years cooking at different places… I’ve been fired from some of them, though… wha’eva! Some very exclusive places even in Ibiza… oh me gosh! Such a helluva time on that island… got laid almost every day… I used to be a hot chick… hot, hot hotty totty… Nothing to do with now, look at me! I’m an awful scarecrow… the burden of crazy, tough years and some dickheads I found on my way too… well, to the point luv, I’m always beating around the bush… they sacked me not because I was bad at my work, I was fucking great, but because I lose my mind sometimes and go crazy, especially when they get on my wick, so many slugs fucking around…’
I interrupted him at that point ‘What about your family?’ He carried on ‘Oh me gosh! My dad died ten years ago and mum passed away six months ago’ And he burst in tears right there for a brief, endless time while I fell silent, trying to comfort him, handing him a tissue to recompose his now non-existing mascara ‘Any brothers or sisters?’ I ventured ‘I’m sorry doctor’ he started ‘my mother was a marvellous person, the only one who has truly loved and understood me in my fucking life. I have two older sisters but they only care for themselves. Juana she’s already quite busy with her mean husband, the old chap has never liked me nor I have ever liked him back. My sis Antonia got divorced a year ago and she is raising her two kids aged 14 and 16… she is having a horrible time, she’s on benefit at the mo and Andrés doesn’t give her a penny for the children. I’m also meself on the dole, been sacked two weeks ago and dough’s gone. Life’s hard, y’know, I can’t even pay my bills and I’m living at mum’s while I still can… But the cunt my sis Juana is married to wants me out to sell the house, he even went to court and now I got an eviction order as a birthday present… so… y’know what I mean? Where on earth I’m supposed to go, nobody cares about me, after everything I did for them for fuck’s sake… Back in my hometown everybody dislikes me for queer; I’ve been through so much, y’know… The thing is I’m not feeling good, doc, I only want to disappear for ever… I shall cut my veins or something to meet mum again… I can’t carry on any more.
The interview carried on for much longer but I will not stretch it on more. Anyway, after the diagnosis of adjustment disorder with mixed symptoms and borderline personality disorder, I wrote the report and thoroughly explained the treatment to him focussing on how to use properly the drugs I was prescribing for him in order to ease his symptoms. As I said before, we had talked at length about how he could channel his frustration due to his lack of acceptance of his sexuality; about how he could, taking advantage of his own past experiences, face the future, both his professional career, housing and many other issues. Finally, I advised him to request appointment at his nearest health care centre for monitoring and psychotherapy.
I’m not sure what I did wrong, it may had been treating him more sweetly than he was used to, may it had been the fact of being overly empathetic, who knows, the point is that when I was going to discharge him I noticed that he wanted to take my hand ‘affectionately’, as if I could understand his point. I thought to myself that how briefly someone can develop erotomania... Anyway, I tried to mend his misinterpretation as respectfully as I could so he just leaned back and apologised with resignation. However, he asked if he could know my phone number in case he may need it later, to which I naturally refused mostly because I could not be his psychiatrist in the future and also because I usually do not give my phone to my patients, I want to preserve my private life private, basically. He perfectly understood me, thanked me for how nice I’d been to him and pointed out that he was feeling very relieved and that his previous suicidal ideas had vanished by magic. After that he stood up and before leaving he campily blew me a kiss of his lips rough with bad implanted silicon. Then I saw him ponce around before disappearing through the A&E gate. I remember him as a nice experience, professionally speaking, of course.
Let me now be a bit more scientific and describe some of the features of MI, of course I don’t mean this to become a lecture the like of those masterly given by my admired colleagues and friends José Martínez and Marifé Lozano within the training of new psychiatrists.
First, I shall say that according to Dr Xavier Amador, a clinical psychologist and professor at Columbia University, who I had the honour of speaking with on several occasions, MI has four fundamental principles:
1. EXPRESS EMPATHY. Expressing empathy towards a participant shows acceptance and increases the chance of the counsellor and participant developing a rapport.
2. ACTIVE or REFLECTIVE LISTENING. Listen to your patient’s story with no prejudices, do not interrupt him or her unless it is essential, with no personal assessment or superior-like perspective, let your patient feel free to speak out their mind and feel the counsellor understand their situation so he or she can trust both the professional guidance throughout change and the patient’s own capabilities to change successfully.
3. REACH AGREEMENT. Know very well what the real need of your patient is -physical or mental issues, addictive or unhealthy behaviour… most times patients aren’t always really aware of this before we approach them this way- Agree with your patients the starting point and help them to set goals.
4. SET AN ACTION PLAN. A set of therapeutic measures and the strategies necessary in case of relapse. And help them to understand that occasional breakdown is concomitant to the change process.
The main difficulty about MI in clinical practice may be the lack of time available to prompt and maintain a process of change and, on the other hand, the difficulty the patient meets when dealing with ambivalence (DECISIONAL BALANCE) between two opposite ideas: minuses suck as disease, issues, addictive behaviour…; and pluses, mainly the goal to achieve when our patient desires to correct their primary problem.
Precisely the hardest and most exhausting part for the therapist is to ROLL WITH RESISTANCE. All of us find difficult to make changes in our habits, regardless how aware we are of their harmful nature. This resistance results from fear of the unknown, fear of being unable to make that change for our own lack of self-efficacy and trust, so this pernicious conduct is rooted in our personal history.
I want to thank especially the MI co-founders and promoters Dr William R. Miller and Dr Stephen Rollnick. Thank you for all your teachings.
As I have already said, MI is a key strategy in my daily job and try to apply it rigorously to each and every one of the patients I see in the clinic and in the A&E department, although I know its limitations: it isn’t always possible to apply every step of this approach given to the lack of time, because not all patients are willing to make drastic changes.
MI goes beyond being an approaching tool to almost all mental illness; sometimes it sets a starting point for some other more specific and better-established theories. Regarding to schizophrenia, the most classic example of mental illness, MI can be also used introducing minor changes.
Life is like a pendulum, each of us swing to and fro at every time. The point is the ability to stop at one point and enjoy it before pushing the ON button to swing to the opposite side. Phew! What fascinating dizziness.
If you stop at a spot of the pendulum tour you dislike, let yourself release and go; get momentum forwards and inertia will lead you to a more comforting spot. If you're open to suggestions and positive interactions, take advantage of them, those will help you advance through the iron and glass jungle, but do never forget that you are the sole responsible for your actions, accomplishments, goals, vices, and tools and toehold to pull yourself up. Sometimes you’ll have to be assertive and stand up for yourself.
If you sense hostility, do not waste time trying to repel it not let them pester or obfuscate you; ignore it and focus on what's important. Sort out your priorities and defend them as if your life depended on it. Be yourself, prove your value, value yourself and let yourself be, being is the most precious thing we have.
Material things shouldn't dazzle you, we need then to live, but getting them should not take the bulk of our time. CARPE DIEM.
We must never forget who we are and where we come from; life turns and we can always return to the same place again.
And once the storm is over, you won’t remember how you made it through, how you managed to survive. You won’t even be sure, whether the storm is really over. But one thing is certain. When you come out of the storm, you won’t be the same person who walked in. That’s what this storm’s all about.