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
Petrus Rypff
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.
THE PENDULUM
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.
(Petrus Rypff)
We must never forget who we are and where we come from; life turns and
we can always return to the same place again.
(Jorge Bucay)
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.
(Haruki Murakami)
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