SISTEMA DE ACONDICIONAMIENTO E INSTALACIONES

Key Skills: (a) reflective statements that acknowledge and validate anger; (b) autonomy statements to support a patient’s sense of self-efficacy; (c) open-ended questions to explore the situation in greater depth and discover what might be required to resolve the conflict.

Tips: Regulate your affect and be aware of your body language. Stay aware of becom-ing defensive and resist the need to justify your decision makbecom-ing when it is questioned in a mocking or sarcastic manner. When you feel an impulse to justify a decision under these circumstances, think about framing your perspective such that you clarify your intent to promote adaptive coping behaviors. A communication style geared toward shared decision making is another way to remain person centered.

One morning, one of my colleague’s patients stormed into the interview room before we had a chance to call him by name and began an angry tirade, claiming that we had discontinued one of his “as-needed” medications last night and “tricked him.”

He was yelling, pointing fingers, and at one point, he angrily dismissed the trainee saying, “I don’t care what you have to say, I need to talk to the real doctor.” This came out of the blue, in the wake of three or four good MI sessions with the same patient.

Here are some examples of my colleague’s responses:

• “You’re really pissed off right now and feel really disrespected.” (Reflection of emotion)

• “It’s difficult for you to trust people and you feel like the team has let you down.”

(Linking past information to the reflection to reinforce rapport)

• “What is anger like for you?” [The patient didn’t understand this question] “I mean, what’s that like for you?” (An evocative open-ended question. It is very useful to focus on the underlying emotion when you feel stuck)

• “Yesterday you shared with me how you were able to manage your emotions during an argument in the kitchen. How were you able to do that so skillfully?” Or “What made that successful?” Or “What has helped you cope/be effective in the past when you’ve been really angry? (Supporting and reinforcing self-efficacy)

• “We’re not doing anything for you . . . what is your idea of treatment?” (Repeating patient’s last statement, clarifying, and exploring)

• “Anthony, do you mind if I share my perspective with you? [Waited for permission]

“You’ve mentioned that no one listens to you and no one is helping you. Personally, I find it very difficult to hear you and appreciate what you’re feeling when you yell.

101Motivational Interviewing in Challenging Encounters I wonder if people shut down when you start to yell . . . communication breaks down and your needs aren’t met. What do you think about that?” (Sharing a per-sonal opinion. Always ask permission first and be very careful to adopt an empathic nonjudgmental tone)

KEY POINT

Reflecting emotion with an angry patient is a key skill the enables “coming alongside the patient”.

This particular patient responded very well to my colleague’s personal disclosure.

He sat down, lowered his voice, and agreed that yelling was not the most effective way to communicate. Later in the interview the patient explored further the roots of his tendency to always think the worst in people and how he could act differently in the future. It’s worth emphasizing that the trainee maintained a neutral but concerned affect throughout the encounter. Her body language was relaxed and she did not focus on content (e.g., which medication, why it had been stopped, that he had been told it was going to be discontinued). She focused on the process of interpersonal relatedness while maintaining a person-centered approach using MI skills and strategies and suc-cessfully defused what had the potential to be an aggressive exchange.

The “Overwhelmed” Patient

Key Skills: (a) reflections; (b) affirmations; (c) supporting self-efficacy.

Tips: Acknowledge tears. Stay in the emotional moment. Adopt a neutral affect.

Choose tones that resonate with the patient’s emotions. This approach diminishes dis-cord in the relationship. Evocative questions help patients continue to explore their emotions.

I used to be extremely uncomfortable whenever patients became overwhelmed and began to cry. Do you tend to ignore it? After all, most people seem embarrassed to cry in front of a stranger. Do you offer a supportive moment of silence and then move on with the interview? In one particularly cringe-worthy situation, a patient was sob-bing while intermittently apologizing for not being able to “get a hold” of herself. My response was, “Don’t be sorry” and was as empathic as it was effective. Following is a transcript in which I found myself in a similar situation:

Patient: [Starting to tear up]

Trainee: I can see that your eyes are starting to fill with tears . . . what are the emotions you’re feeling right now? (Acknowledge tears, stay in the emotional moment, and explore with an evocative question)

Patient: Scared, ashamed . . . my life is ruined. I can’t recover.

Trainee: You feel like you’ve passed the point of no return. (Complex reflection) Patient: Yes. I’m sorry, I need to stop crying and get it together.

Trainee:  You feel embarrassed. (Reflection of the underlying emotion, instead of responding to the content)

Patient: Very embarrassed. I’ve tried to stop drinking so many times before, but this time is different. I want to recover.

Trainee: You want to learn how to start coping with feelings in a different way that doesn’t involve alcohol, and you see yourself being determined this time . . . What

Motivational Interviewing102 does it mean to you to recover? (Transitional summary followed by an evocative question that guides the patient forward)

Patient: I believe I can do it . . . but I’m scared.

Trainee: On one hand, you are afraid to try again, and on the other hand, you’re deter-mined in a way you haven’t been before. (Double-sided reflection. Always end with the emotion that will mobilize the interview instead of creating a roadblock, which is what might have occurred if the sentence was structured the other way around.

Use language that builds self-efficacy) You mentioned earlier that you did not use substances for 8 months. How did you successfully stop for those 8 months? (This affirms self-efficacy and continues to move the encounter forward. Also note that, although it is in our common parlance, the word “clean” is judgmental while the term “not using substances” is less so)

By making the effort to acknowledge this patient’s obvious emotions, and by exploring what they meant right now, this patient and I were able to extend this understanding to the bigger concerns in her life, namely, those related to alcohol abuse.

The “Disengaged or Withdrawn” Patient

Key Skills: (a) acknowledge patient autonomy; (b) astute reflections; (c) affirmations.

Tips: If a patient says he or she doesn’t want to talk, it is worth respecting this auton-omy and negotiating another time to engage. It may be less convenient for you, but it furthers rapport and provides a good foundation on which to base the next encounter.

Consider offering explicitly understanding acceptance as to why it may be too difficult for a patient to engage at this particular time. For example, the patient is experiencing significant withdrawal symptoms from drugs or alcohol, or is exhausted after having just been admitted following a long night in the emergency department. Acknowledge that the patient is struggling and respect his or her wish to meet later. Depending on the context, you could attempt to engage your patient by reflecting that he or she has really been struggling lately and follow this observation with an open-ended question as to how he or she was able to walk into the room and reach out despite these struggles. Try to resist feeling uncomfortable either with silence or with slowing your pace. MI is about meeting patients where they are, both in the content of your reflections and the pace of the encounter. This can be particularly challenging in a medical setting in which we are under intense time pressures. However, slowing down and using carefully chosen effec-tive language will actually save you time and better serve your patient in the end.

An older gentleman with a long history of alcohol abuse was involuntarily committed to our hospital after making homicidal and suicidal statements in front of police officers.

He was a small, quiet, gentle man who spoke in one-word replies. At first, I was caught off guard because he did not fit the “usual” patient profile of an involuntarily committed individual who is angry and rebellious. Here is an excerpt from our second session:

Trainee: Hi, John. How have you been feeling since we last talked?

John: Fine, I got some rest.

Trainee: [pause] Some rest . . . (Simple reflection, echoing his words) John: I’ve been gathering my thoughts.

Trainee: [pause] You have had a chance to rest, to be still, and reflect on what has happened as a result of your actions. (I specifically used the phrase “your actions,”

103Motivational Interviewing in Challenging Encounters instead of “recent events” or “what brought you in,” because my goal was to main-tain a person-centered approach and place subtle emphasis on the fact that it was his actions and not “the alcohol” that led to his admission. Recall that MI aims to evoke a sense of autonomy within patients, rather than implying or assuming passivity)

John: Yes.

Trainee: When you say, “gathering your thoughts,” what do you mean? (Evoking) John: I realize that when I’m depressed I shouldn’t drink. I should make a phone call

instead or try a different vice. (The patient is presenting reasons for change elicited by the open-ended question)

Trainee: Drinking is not something you want to do in the future . . . you really see a connection between your depression and drinking alcohol. (Reflection emphasiz-ing how depression and substance use are linked)

John: Yes.

Trainee: John, how were you able to come to the conclusion that drinking is affecting you? (Open-ended question)

John: Well, take smoking [cigarettes] for example. I can go for 2 days [that is, since admission to the unit] with no nicotine patch, and be fine. Why can’t I do that with drinking?

Trainee: You’re drawing a comparison between smoking and drinking. You realize that you’re coping without cigarettes and want to do the same with drinking. John, help me understand, what drives you to drink? (Transitional summary statement followed by an evocative question)

John: Well, sometimes it’s the taste, but other times I don’t like the taste. I want to drink because I’m pissed off or depressed. Sometimes it’s because my friends will be in the bar, playing pool, shooting darts, you know. . .

Trainee: There is the social aspect of being out with friends, as well as some of the characteristics of alcohol . . . at the same time there are also times where negative emotions drive you to drink. (Double-sided reflection, linking in past information)

John: Yes. Some people blame alcohol for their actions or say it caused their depres-sion, but I know I drink because I’m depressed, period.

Trainee: John, I really appreciate you sharing this with me; it’s not easy to sit in that chair. You pride yourself on being strong for others and you’re realizing now that you need to be strong for yourself, too, by being honest and open about your strug-gles. (Affirmation, encouraging the patient without “cheerleading” responses, such as “That’s great,” “That shows good insight,” or “Good for you”)

Looking back on this encounter, I remember how challenged I felt to remain quiet within myself, while remaining fully attentive and present to this patient’s reserved, subdued manner of speaking. Had I not been able to respond to his stillness, I wonder now whether I might have missed the remarkable insights we gleaned together over the course of this interview.

The “Manipulative or Entitled” Patient

Key Skills: (a) address thought process rather than content; (b) complex reflections such as amplified and double-sided reflections; (c) autonomy statements and affirmations to

Motivational Interviewing104 communicate that they are in control of their emotions and their behaviors, particu-larly when loss of control is suggested or threatened.

Tips:  A  neutral/relaxed or pleasant/concerned affect is ideal, as is relaxed body language.

During a medical rotation I was called to the floor because a patient on the ward was “freaking out.”

Trainee: Hi, Jessica. What’s going on right now?

Jessica: I’ll tell you what’s going on—it’s you people and this place. I come here in agony, somehow am able to reach out for help, and then I get nothing in return!

Tylenol® isn’t going to cut it. I told you this and I’m not stupid, you know! Only Norco® works for my chronic pain!

Trainee sample response 1: Well, Jessica, as we spoke about earlier, Norco® is not indicated for your pain as we cannot find a pathological cause of your pain.

(Defensive, directly responds to content and intellectualizes)

Trainee sample response 2: Jessica, I can see how frustrated you are right now . . . it took all your energy to come here and you feel that coming here was a waste of time because you’re still in excruciating pain. (Complex reflection that addresses thought process and not content)

Trainee sample response 3 [Should the patient continue to be riled up]: It’s hard to communicate when you’re yelling. Would you like me to give you a couple of minutes to cool off? Let’s see what’s happening right now. I’m a little confused because this morning you were much calmer. (Set limits and also allow the patient a degree of control because internally, the patient feels stripped of it. Acknowledging some personal emotion makes you more of a real person and less of a threat.

The risk of responding directly to content is that such a stance will likely place you in opposition to your patient, thereby sending you into what I call “interview purgatory,”

that is, a neending debate about your medical management versus their reality ver-sus your credentials verver-sus what they know is true, and so on. Direct insults, sarcasm, rhetorical questions, and challenges to medical decision making are situations rife with potential content traps. Addressing your patient’s thought process puts the focus back on the patient in a therapeutic and nonconfrontational manner. It is perfectly reasonable to share a personal opinion, similar to sample 1; however, it is better to preface this activity by first seeking permission to do so and then asking for feedback on your opinion after you have shared it. Another useful strategy is to offer the patient a list of available options.

Shea describes seven “core pains” that interviewers should keep in mind when try-ing to assess and better understand how the “manipulative” behavior, or any form of observable resistance, comes about:

1. Fear of being alone 2. Fear of worthlessness

KEY POINT

Stress autonomy with an entitled patient to further establish therapeutic alliance.

105Motivational Interviewing in Challenging Encounters 3. Fear of impending rejection

4. Fear of failure

5. Fear of loss of external control 6. Fear of loss of internal control 7. Fear of the unknown

“Manipulative” or “entitled” patients have learned to fill these voids by manipulat-ing and controllmanipulat-ing their environments, thereby also servmanipulat-ing to protect their fragile sense of self. How do they achieve this? They attack your sense of self . . . along with everyone else’s. What a shock it is when you respond in a steady, controlled manner designed to deescalate the situation.

“Manipulative” or “entitled” patients are the patients we struggle with most.

Like delirium, manipulation can present in either a quiet fashion or a very obvi-ous one. However, unlike delirium, these interactions seem to pierce right into our core, our very sense of self. They shake us up enough to ruin a morning, a call shift, or even longer. “Flight” is not an option; so instead, we prepare ourselves to

“fight.” The defense we often use is to put up an emotionless wall that has a two-fold benefit: our countertransference cannot get out, and the patient’s enraging words or behaviors cannot get in. We quickly learn that this is not a sustainable coping mechanism when phrases such as “Who cares if she leaves, I’ll be glad!”

dare to creep into our minds or when we dread the thought of another challenging patient. This still happens from time to time, when we are tired or having a dif-ficult day. Yet it takes all of 10 seconds to remind ourselves that no one wins this way: it is a lose-lose situation. Remember that when we view our interactions with patients as a battle with winners and losers, then we have the MI approach to use.

Once you feel confident about using the strategies we have discussed, your options when dealing with “manipulative” or “entitled” patients will now consist of “fight,”

“flight,” or “use MI.”

The “Nonadherent” Patient

Key Skills: (a) explore beliefs and underlying ambivalence; (b) develop discrepancies, that is, how the individual’s current behavior or consequences contradict his or her values/beliefs/goals for the future; (c) respond to discord.

Tips: “Why” is a word best avoided when incorporating MI into encounters with our patients. It’s subtly judgmental and can limit patient engagement, rather than evoke more change talk. Instead of asking “Why?” pose questions such as “What leads you to. . .?” or “What makes it difficult for you to. . .?” Remember that the dyad formed through MI, the interpersonal process itself, is what helps to bring about motiva-tion for change. Motivamotiva-tion is the behavior itself. Something to ponder, then, is this:

Could it be that your patient who has presented to the emergency department with a heart attack, and who hasn’t taken her blood pressure and anticholesterol medica-tions, might be intrinsically “unmotivated” or “noncompliant”? How can patients be expected to act out their physician’s monologue?

KEY POINT

Avoid questioning a nonadherent patient’s behaviors with the pejorative “why?”.

Motivational Interviewing106

Elicit values and explore conflict between core values and behaviors

Use OARS skills within the context of the spirit of MI to build discrepancy

As ambivalence is guided toward the direction of change, change talk emerges

The continued use of MI adherent discussion further mobilizes the patient

Commitment talk emerges Patient ambivalence about maintaining

problematic behaviors

FIGURE 8.1 Mobilizing patients by developing discrepancy.

Patients with concurrent psychiatric and substance use disorders often sense that these issues get in the way of the person they would like to be, whether mother, father, son, daughter, boyfriend, girlfriend, or perhaps even the person a now-deceased relative had wanted them to be. These feelings are an extremely powerful conduit for change. Religion may also prove very important. Family members of patients who do not adhere to medication or treatment regimens, or who fail to attend medical appointments, are often upset about this behavior and their reactions can also become a stepping-stone to exploring ambivalence and developing discrepancies.

Consider the following summary, in which the arrows mean “leads to”:

Discrepancy/conflict between behavior and core values → ambivalence about continued sustained versus changed behavior → through MI, discrepancy increases and ambiva-lence is guided in the direction of change → the process of change is mobilized and

Discrepancy/conflict between behavior and core values → ambivalence about continued sustained versus changed behavior → through MI, discrepancy increases and ambiva-lence is guided in the direction of change → the process of change is mobilized and