A FINAL THOUGHT

One of the most subtle but powerful skills in the toolbox is “reflection.” And one of the most important parts of one’s training is learning how to take risks with reflections, even in uncomfortable or emotionally fraught encounters with patients. In fact, the ability to do so can be developed by honing one’s skills for reflective listening.

A middle-aged woman who appeared much older than her stated age presented the day after admission to an inpatient psychiatric ward. Not having more refined MI skills, I asked her, “What brought you into the hospital?” She said, “Been out running the streets . . . you know.” I didn’t know. She shared more with me during the session as she told me that she had spent many recent days (and nights) using drugs and foraging in dumpsters for food. She shared with reluctance and appeared ashamed of herself. Then she also told me that she was worried about her health as she also had been prostituting herself with strangers without any protection against sexually transmitted diseases. Uncomfortable, I reassured her that we could order the relevant testing and treat her accordingly, depending on the results. But she was not reassured.

It was still so clear how ashamed she was feeling. And there was silence between us, as it was apparent she had other concerns that were at least as significant as her medical worries.

“I have been away from my kids, and I have been whoring myself out for drugs instead,” she said, peering up at me from beneath her hanging head. I was startled by her candor, unsure of what to do next. I had an impulse to ask a question or reassure her or even change the subject to something I was more comfortable with. But I had the sense that she wanted to know that I could accept the struggle within her that she was now sharing with me.

Unsure about the sensitive emotions of our engagement, I offered a reflection, but not without having some concerns that it would be too far ahead of ourselves or even too presumptuous on my part: “Some of the decisions you have made have not always led to your being the person you wanted to be.” “That’s right,” she replied, “I never planned to be this person. I’m tired of being this way.”

Motivational Interviewing56 Her having the courage to be open about where she had fallen short of herself let me take the risk of meeting her where she was by using a reflection that was just a bit ahead of where we were together. Of all the issues that were to be part of our agenda during that inpatient engagement, this struggle within her was the central point around which we were able to organize our sessions together and link to other items like spokes to a hub. Even apart from the humanity that I learned from this episode, I learned that while the more technical aspects of MI (like meeting the individual where she is and focusing on an agenda) are important, the basic tools of MI (the OARS) are indispensable. By being able to use them (especially reflections), I feel more confident about facilitating those moments that might otherwise be so emotionally sensitive that I would miss facing them together with the patient who had the courage to share them with me in the first place.

SELF-ASSESSMENT QUIZ True or False?

1. The transtheoretical model (TTM) or stages of change model (SCM) arose from the early work and development of MI.

2. When working with patients in the precontemplation stage, it is best to con-front them directly regarding the negative consequences of their unhealthy behavior(s).

3. A hallmark of the contemplation stage of change is ambivalence.

4. An example of a well-formulated open-ended question is, “Can you tell me how you were able to take your medications in the past month?”

5. A good example of an affirmation is, “I’m very impressed with the work you’ve done, and it is clear to me that changing this behavior is very important to you.”

6. Reflections may be understood as a means to test an hypothesis, and they help trainees make informed deductions regarding the underlying emotions or mean-ings of a patient’s statements.

7. Summaries allow trainees to demonstrate that they have been listening, have understood what patients have shared, and that they are interested in exploring a patient’s experiences and perceptions.

8. Three sources for agenda-setting information include patient, trainee, and clini-cal setting.

9. Of the three key focusing styles, MI is most closely aligned with directing.

10. Elicit-provide-elicit (E-P-E) is a framework that facilitates trainees’ ability to offer an expert opinion or clinical information in a way that maintains collaboration with the patient.

Answers

1. False. The transtheoretical model or stages of change model was developed by Prochaska and DiClemente through their work with individuals who overcame nicotine and alcohol addiction. They identified five unique stages: precontempla-tion, contemplastages: precontempla-tion, preparastages: precontempla-tion, acstages: precontempla-tion, and maintenance. Although TTM shares a common heritage with MI and provides a conceptual model to understand change, there is no formal theory that links the two together.

57Building a Toolbox 2. False. A confrontational approach to patients in any stage of change will create

problems. Patients often become defensive in response to confrontation, and any therapeutic alliance will be threatened. Instead, a more effective approach is to ask patients for additional information and express genuine curiosity about their present lives and how they understand the behavior of concern.

3. True. Ambivalence is a highly-common experience in which patients hold dis-parate views their behavior(s), and debate the many reasons both for and against change. Ambivalence is a defining feature of the contemplation stage and should be viewed as progress, as compared to precontemplation stage.

4. False. Although the second half of this question may be considered open ended, including “can you” at the beginning makes it close ended. Eliminating this restrictive phrase frames the question in an evocative way: “Tell me how you were able to take your medicine over the past month.” This is now a fine open-ended question that encourages this patient to elaborate on past successes in following medication routines.

5. False. Although this statement may be well intentioned, the use of “I” state-ments in affirmations is discouraged; they shift focus away from a patient’s experience and have the potential to be perceived as ingratiating or patron-izing. Remember that MI is patient-centered; affirmations are best when they begin with “you.”

6. True. Reflections allow trainees to demonstrate active listening, enhance com-munication, and encourage further exploration of a patient’s experiences and feelings.

7. True. Summaries confirm active listening and function as helpful transitions.

Collecting statements gather and organize interrelated elements that a patient has shared. Linking summaries allow trainees to identify themes within a patient’s conversation by linking components in the present conversation with topics or points shared by the patient earlier in the same conversation or perhaps on previous occasions. Transition summaries capture key points within the present conversation and subtly shift focus to a different thread of conversation.

8. True. Although a patient always remains at the center of treatment, it is helpful to take into account the setting in which an interaction takes place and a trainee’s degree of clinical expertise. Together, these three sources contribute to the cre-ation of an appropriate agenda.

9. False. As discussed in Chapter 2, MI is a guiding style that falls between directing and following, when viewed along a continuum of communication styles. With a directing approach, trainees dictate the progress and topic of the exchange, whereas following is a passive approach.

10. True. The patient-centered quality of an exchange may easily be compromised when trainees behave as clinical experts. When sharing knowledge and informa-tion with patients, the elicit-provide-elicit framework ensures that atteninforma-tion remains where is should be: on the patient. This technique works in three ways: determining what a patient needs or wants to learn about a particular topic;

sharing the relevant information; and asking the patient for his or her thoughts and impressions of the material that was shared.

5 Motivational Interviewing in Practice

The fundamental encounter of any healthcare setting occurs between an individual seeking care and the person whose duty it is to alleviate suffering and promote health. Within the context of motivational interviewing (MI), each of these two individuals assumes a significant role within a highly dynamic process directed toward initiating behavior change, while at the same time respecting patient auton-omy. MI affirms each patient’s capacity to identify problematic behaviors and to select from a range of possibilities those initiatives most likely to bring about and sustain healthy alternatives. This chapter incorporates the core behaviors discussed in previous chapters and expected of MI-experienced trainees: a patient-centered approach, the clear expression of clinical empathy, the use of collaborative lan-guage, and the evocation of goal-directed communication.