La exigencia de un título para el ejercicio de una profesión, implica que sólo pueden llevar a cabo esa actividad, las personas que hayan obtenido

Devon* (*name changed to protect privacy) is a 20-year-old African American man, with a history of end-stage renal disease (ESRD), who requires hemodialysis. He is scheduled for Monday, Wednesday, and Friday hemodialysis sessions. Devon missed a session on a Friday and subsequently presented to the emergency department (ED) the following Sunday with shortness of breath. When he came in the ED, Devon was found to have a systolic blood pressure in the 190s, and he was sent for emergent dialy-sis with a planned admission to the intensive care unit (ICU) after his dialydialy-sis session.

After finishing his dialysis session, Devon was transferred to the ICU. Following is an excerpt of the exchange that occurred between the medical resident and Devon during the interview. (Note: Devon is a thin African American man slumped over in bed not making eye contact with the medical resident.)

Resident: (regarding dialysis) Devon, when do you go for dialysis?

Patient: [No response]

Resident: Isn’t it every Monday, Wednesday, and Friday?

Patient: [No response]

Resident: And you missed your dialysis session on Friday, right? What happened?

Motivational Interviewing72 Patient: [No response]

Resident: Come on, Devon, the sooner you answer me, the sooner this will be over.

Patient: [No response]

Resident: Now, why did you miss your dialysis session on Friday?

Patient: [No response]

Resident: How do you usually get to dialysis?

Patient: The bus.

Resident: What happened Friday then? Did you miss your bus?

Patient: [No response]

Resident: I know you had some trouble breathing, but we need to make sure you’re ok and that nothing else is wrong with you. Was there anything else going on other than the shortness of breath?

Patient: [No response]

Resident: How about a headache? Are you having a headache?

Patient: [No response]

Resident: [Louder and now pointing to his head] Devon, does your head hurt?

Patient: [No response]

Resident: Devon, I need you to answer me. Does your head hurt?

Patient: [muttering] No.

Resident: Good. How about your vision? Any blurry vision?

Patient: [No response]

Resident: [Louder again] Come on, Devon, is there anything wrong with your vision?

Patient: [shakes head no]

Resident: [pointing to chest] Are you having any chest pain?

Resident: Do you know why you are in the ICU?

Patient: [No response]

Resident: With you being as hypertensive as you were, you could have a stroke, dam-age your eyes, or have a heart attack [pointing to each area in turn]. Can you repeat after me so I know you understand what we’re concerned about?

Patient: [mumbling] Stroke, blindness, and heart attack.

Resident: Good.

This clinical encounter is an example of major discord in the therapeutic relationship that was perpetuated by the trainee’s use of a deluge of consecutive closed questions with no intention of allowing the patient to share his perspective.

Historically, the word resistance has been used to describe any number of patient characteristics and behaviors that represent an unwillingness to comply with the practitioner’s expectations, for example, to come to appointments on time, to accept responsibility for the specific behavior, to follow treatment recommendations, and so on. The construct implies that failure associated with maintaining a therapeutic alli-ance or making progress in treatment lies with the patient. In MI parlalli-ance, the term

“discord” was recently chosen as a more accurate term to signify an impasse in the therapeutic relationship. The thinking behind changing the descriptor is that treat-ment involves the attitudes and behaviors of two people interacting with each other and problems that develop in clinical encounters are related to both the patient and the practitioner. It is important to identify the clinical encounters where a patient could have a discordant relationship with a practitioner and still express change talk.

Alternatively, a patient could be engaged with a practitioner while expressing sustain

73Ambivalence and Discord talk. A continuing tenet of MI is to keep discord to a minimum in the therapeutic encounter.

Dealing With Discord

The best way to minimize discord is to behave in a manner that prevents it. When you are practicing MI at a high level, your relationships with patients originate from a clear understanding of your responsibilities.

Trainees are responsible for the following:

• Maintaining the structure of treatment so that they meet with patients at the appointed times and allow patients access to them as specified in an agreement made at the beginning of treatment, for example, no contact outside of scheduled appointments; telephone, e-mail contact; and emergency appointments allowed/

not allowed, and so on

• Maintaining patient confidentiality as is specified in the treatment agreement

• Offering your best efforts to create an environment where patients can explore their potential for change, including recommendations/referrals to other treatments or interventions according to the trainee’s clinical judgment

Implied in these responsibilities is that trainees: (1) make no moral judgments about patient behavior; (2) respect patients’ rights to self-determination; (3) recognize that they have no control over patients’ behaviors; and (4) are not responsible for “fixing”

patients or otherwise solving their problems.

When you approach patients in this neutral, objective manner, you are not engag-ing in “resistance” toward the patient and, therefore, patients find little to resist or argue against.

Notwithstanding this approach, discord can occur in therapeutic relationships. It may be related to the way you feel about a patient that affects your objectivity (what psy-choanalysts call “countertransference”). Sometimes it is due to your reacting overtly to a conflict between your views or priorities and those of the patient. Sometimes patients feel that their autonomy is being impinged upon. Sometimes one or both of you is tired, ill, upset, or distracted by something completely unrelated to the medical encounter.

Your actions can increase or decrease discord. Behaviors that can elicit or enhance discord are as follows:

• Arguing for change or insisting on a single path toward change

• Lecturing, preaching, or presenting yourself as the expert and making rational arguments to “prove” your case as to why patients should change

• Ordering or commanding patients to make specific changes

• Warning, threatening, or using scare tactics to manipulate patients to change

• Failing to allow patients to provide their perspectives and cutting them off

• Shaming, ridiculing, or blaming patients about their beliefs, experiences, behav-iors, or health status

• Expressing pessimism about patients’ ability to make changes

• Failing to recognize and affirm or, even worse, criticizing patients’ efforts

• Being in a hurry

• Giving general reassurances or “pep talks” that everything will be okay

Motivational Interviewing74 Such behaviors can be an inherent part of treatment in busy clinics or hospitals. The demands made on trainees’ time are onerous, and it is normal for these confronta-tional behaviors to become standard practice in clinical encounters.

When discord arises, pay attention to your emotional responses. It is difficult to not take conflict personally. However, you can learn to stay calm and to think before you react. Consider why the patient is behaving this way. Think about what you may have said or done to evoke this response. Summarize your view of what is happen-ing between you and the patient and ask for his or her point of view. Patients may be reacting to something outside of treatment, and this is important to know. If a patient is concerned about something in the encounter or has taken offense and he or she is expecting an apology, apologize or further explain yourself without hesita-tion. This is part of the MI focus on a transparent, egalitarian approach that reduces discord. Other strategies that can be of help include reflections as they pertain to sustain talk.

Reflections:

• “You don’t want to be here, and you’re angry that your wife made you come.”

• “You’re sick and tired of people telling you what to do. You’ve been dealing with this for a long time, and you feel that you’ve heard it all before.”

Notice how these statements reflect the content and the feeling that patients may be experiencing. Such reflections of emotion show patients they are understood and you are concerned. As a result, patients feel more comfortable to elaborate on their concerns.

Reframing:

• “It seems like nagging to you because she does it constantly. When people do that, it’s often because they are nervous or fearful that something bad will happen to the person they love. It’s possible that your wife is worried about you and this is how she expresses it. You know her best. What do you think?”

• “You didn’t like that I gave you suggestions about how to cut down on sugar and fat in your diet. It’s obvious that you’ve got your own ideas about how you might approach this. I take responsibility for not asking you about your ideas first. How about discussing how you see it?”

Emphasizing personal choice and control is also important. As you respond to your patients’ statements and behaviors, continuously include references to their freedom to choose because it is their responsibility for decisions and what comes out of them. Do this in a matter-of-fact manner without emphasis on the patient being “on an island”

without support. You do this by simultaneously reminding patients that your respon-sibility is to help them as much as possible to make changes toward leading a healthier lifestyle.

Autonomy support statements:

• “You are the best judge about what changes make the most sense to you and how you want to make them. What steps do you see yourself starting with?”

• “I am not here to tell you what to do or try to make you do anything you are not interested in doing. How do you want to proceed from here?”

75Ambivalence and Discord Affirmations can also make the interaction less adversarial.

Affirmations:

• “I appreciate how hard it must have been to come in here and talk with me about this. You are a strong person to keep working on this.”

• “You are making a valid point. You have been very resourceful and thoughtful about what might work best for you to be successful.”

• “You worked hard to prevent this from happening and did the best you could.”

Shifting focus from the area of contention to a less contentious area that the two of you can agree on can also be helpful. For instance, you might say, “I’m not interested in trying to force you to do something that you don’t want to do. What I am interested in is how we can work together to keep you healthy.” Consider the following exchange:

Patient: “I can’t ask my boyfriend to start using condoms now—he’ll think I am cheat-ing on him or have a disease! I don’t know what he will do.”

Trainee: “You are way ahead of me. I’m not asking you to do something that will jeopar-dize your safety. Help me better understand your relationship with your boyfriend.”

Tailor your statements to the person you’re working with. There’s no prefabricated phrase that will solve all conflict. Being interested, accepting, and caring goes a long way.

SELF-ASSESSMENT QUIZ True or False?

1. Sustain talk consists of arguments for the status quo, while change talk argues for the need to behave in a different way.

2. When patients engage in sustain talk, it is helpful to challenge these statements and identify how these views contribute to the unhealthy behaviors in question.

3. The technique of “coming alongside” is used when patients engage in sustain talk.

4. “Discord,” the expression that replaces the term “resistance” in MI, is created solely by patients in the clinical encounter.

5. Refraining from moral judgment, respecting patient autonomy, and rejecting the notion that trainees should be able to “fix” their patients allow trainees to approach patients in a neutral and objective manner, which in turn, reduces the potential for discord in their relationships with them.

Answers

1. True. Sustain talk and change talk result from the intense intrapsychic conflict patients experience as they work through ambivalence; this process demands that they explore arguments in favor of maintaining the status quo as well as those in favor of change. Patients often engage in sustain talk because they lack experience with either the positive aspects of implementing behavior change or success in doing so. Sometimes patients are far removed from a healthy lifestyle and do not recognize that change is an achievable, viable alternative. The goal of MI is to help guide patients to express more change talk and less sustain talk.

Motivational Interviewing76 2. False. Sustain talk is characteristic of ambivalence and is inevitable among those who are trying to bring about significant behavioral change. Trainees should never belittle sustain talk, try to eliminate it, or explore in any depth why patients might not want to change. Instead, trainees are encouraged to engage, or “dance,” with patients by exploring other avenues of discussion, such as clarifying previously discussed change talk, and elaborating patient statements that will shift discussion in the direction of change talk.

3. True. Trainees “come alongside” when they acknowledge a patient’s arguments for the status quo of maintaining unhealthy behavior; this is contrasted against posi-tive goals and aspirations that the patient has stated as desirable as preserving the status quo.

4. False. Historically, resistance was used to describe a patient’s negative response to the therapist or therapy. The word discord was selected by Drs. Miller and Rollnick to signify an impasse in therapeutic relationships. Discord reflects the contem-porary view that problems arising in treatment are related to both patient and trainee. Several common trainee behaviors have been identified as key contribu-tors to discord.

5. True. These principles are fundamental to MI and are essential components in collaborative encounters that help ensure patients feel secure, respected, and con-fident that they can trust a trainee.

7 Moving Ahead

From Sustain Talk to Change