PERSONAL REFLECTION

As I progressed through my medical training, I gained confidence in my clinical abili-ties to gather patient data, analyze relevant elements of the history, and synthesize this data with various test results in order to arrive at a diagnosis. From this point, I would finally determine a treatment plan. But no matter how strong my history-taking skills, no matter how accurate I was at making a diagnosis, I always felt something was miss-ing from my patient encounters. I felt this most acutely whenever the crucial aspect of my recommendations involved helping my patients make lasting behavior change.

It was so frustrating to feel stuck in a fruitless attempt to bring about change with patients who were, well, as stuck as I was.

This is what provoked me to learn MI. While medical school had trained me to be adept at collecting and making use of data, it did not teach me how to establish a col-laborative or therapeutic relationship. As I worked to understand the true spirit of MI, my patient encounters became more humanistic and less focused on purely rational

Engaging. establishing trust and a working relationship Focusing. collaboratively developing direction

Evoking. eliciting patient’s own motivations Planning. making plans for change

FIGURE 3.4 The four processes of motivational interviewing.

Motivational Interviewing28 science. I told myself that I was learning to treat my patients “side by side,” instead of

“head to head,” as I had done previously.

What surprised me most about learning MI was how the spirit of this approach awakened the notion of true patient centeredness within me. Even more surprising was how much more “free” I felt within patient encounters. I discovered that the more capable I  became at helping my patients make their own choices about treatment, the better I felt about my ability to provide sound care. Finally, I understood that my choice of words and tone of voice mattered every bit as much as the laboratory tests and medications I ordered. I found it easier to put each patient’s needs ahead of my own desire for competence and recognition, and I must say, it felt wonderful!

Another epiphany was learning to view challenging patients with compassion, real-izing that these individuals have much to teach me. I know now that when I’m able to stay person centered, I feel more confident in my ability to put my patients first. This has made a huge difference in the way I practice medicine: I feel I’m able to consider all of the relevant data now, not simply the obvious physical findings.

I find it highly ironic that through learning to be patient-centered, I feel as though I’ve given myself the most wonderful gift of my (short) career.

SELF-ASSESSMENT QUIZ True or False?

1. The four key elements of the spirit of MI are partnership, acceptance, compassion, and evocation.

2. In MI, trainees are seen as experts who provide answers and a clear course for patients to follow in order to achieve change.

3. The four As of acceptance include absolute worth, accurate empathy, autonomy support, and affirmation.

4. The four processes of MI are engaging, focusing, evoking, and planning.

5. DARN CAT represents the dimensions of motivation.

Answers

1. True. In a collaborative relationship, trainees do not function as directive sources of advice and information, but rather as equal partners in the behavior changes patients wish to bring about. Trainees accept patients for whom and where they are, with regard to exploring or implementing change. Compassionate medical trainees place patients’ perspectives and welfare ahead of their own. Evocation encourages patients to explore how their experiences and perspectives contribute to their motivation for change.

2. False. The trainee’s role is not to offer or even try to identify all the answers; rather, trainees aim to help patients determine which course of action would work best for them.

3. True. In MI, acceptance is the ideal standard that implies that trainees accept patients for precisely who they are, regardless of their degree of interest or motiva-tion for changing unhealthy behaviors. Acceptance is embodied by appreciating the absolute value of each patient, expressing genuine interest in understanding

29Spirit and Processes of Motivational Interviewing a patient’s worldview, supporting each patient’s right to self-determination, and acknowledging a patient’s strengths and efforts for change.

4. True. Engaging with patients is an essential part of establishing sound relation-ships that allow trainees to understand each patient’s experiences and feelings.

Focusing involves isolating and recognizing the patient-identified goal that is to be explored, developed, and pursued. Evoking builds upon engagement by describing and elaborating a patient’s motivations and arguments for change.

Planning is the process that delineates specific goals and actions to bring about, and consolidate, behavior change.

5. True. The acronym DARN CAT summarizes the types of preparatory and mobilizing change talk used during the evoking stage of MI. The letters represent Desire, Ability, Reasons, Need, Commitment to change, Activation language, and Taking steps toward change.

4 Building a Toolbox

The concept of building a toolbox comes from the perspective that providing healthcare is an interaction that is both work and a service. The interaction of a medical trainee and a patient is the work, and out of it comes improved or new behaviors that “fix” a problem. However, whether anything gets fixed is reliant on the quality of the service, and the quality of service depends on whether the right tools are used to perform the work. Builders acquire tools as they gain experience.

They pick up tools during training and on each job. They learn how to use each tool as it is designed to perform in a particular way. Similarly, medical trainees must also collect techniques or “tools” and learn to use them as part of their interpersonal and clinical skills. They must develop the tools they need to work effectively and then take out each one and use it as needed to fit a particular clinical setting and the individual patients they encounter.

THE WHY AND HOW OF THE THERAPEUTIC APPROACH