A few months ago, a young man—“Greg”—visited Petros Levounis, M.D., director of the Addiction Institute of New York. He made it clear to Levounis that he had no desire to stop using cocaine and marijuana, but had made the appointment because his girlfriend had urged him to.
Levounis told Greg that he respected his position, and they both agreed that the goal of his treatment should be to end it. Or as Levounis recalled recently with a chuckle, “We discussed what we had to do to get him not to come to see me!”
Little by little, a rapport developed between Greg and Levounis. Greg started to admit that his drug use did have some down sides, especially regarding efforts to get established in the advertising industry. And, “well, it would be fair to say that we failed in our goal because I am still seeing him,” Levounis said. “He has become cocaine free. He continues to smoke marijuana every once in a while or perhaps more regularly than I would like. But he is certainly in a much better space than he was when he first came to see me.”
The strategy that Levounis has been using with Greg is motivational interviewing (MI). How many psychiatrists are familiar with it is unclear, but the psychiatrists who talked to Psychiatric News about using the technique in their practices give it positive reviews (see Why Some Psychiatrists Started Using Motivational Interviewing below).
MI is essentially a method of communication for helping patients change problem behaviors such as alcohol use, drug use, smoking, overeating, or not adhering to medical treatment, Joji Suzuki, M.D., medical director of addictions at Brigham and Women’s Hospital and a psychiatry instructor at Harvard Medical School, explained during a recent interview. “You try to help patients move toward change by eliciting and exploring their own arguments for change.”
The spirit of the strategy is crucial, another psychiatrist and MI user, stressed. She is Christina Delos Reyes, M.D., chief clinical officer of the Alcohol, Drug Addiction, and Mental Health Services Board of Cuyahoga County in Cleveland, Ohio. That spirit includes empathy and working together, she said.
Bachaar Arnaout, M.D., an assistant clinical professor of psychiatry at Yale University and an MI user, agreed: “The spirit is in many ways more important than the technique.”
Suzuki concurred as well: “When many patients come to medical or psychiatric settings, and the conversation turns to alcohol or drugs or other unhealthy behaviors, they are ready to argue with you because clinicians have often adopted an educational or confrontational approach. But when you demonstrate that you are going to respect their autonomy and collaborate with them, it lowers their defenses and resistance, and you are able to have a more honest and empathic conversation. That is why the spirit of MI is so helpful if the goal is to increase people’s motivation for change.”
But MI does involve specific techniques, and one of the most important is trying to get patients to talk about how they want to change or are going to change, Carla Marienfeld-Calderon, M.D., an assistant professor of psychiatry at Yale and also an advocate of MI, pointed out (see Learning and Teaching Motivational Interviewing below). “We want to elicit change talk,” she explained, “because that has been shown to be the thing that is most effective in getting people to actually alter their behavior.”
Another valuable technique is reflecting, Arnaout noted. During the conversation, the therapist often repeats or paraphrases what the patient is saying. It gives the patient a chance to hear what he or she has said, to elaborate further, and perhaps offer a correction. It is also an effective way to keep up the flow of the conversation, and it shows the patient that the therapist is listening.
“MI has often been misunderstood as being a very passive therapy,” Levounis said. “Yet that couldn’t be further from the truth. While doing MI, we often explain what we think, and we are very up front about our own agenda as clinicians. But we just make sure that ultimately the decisions rest with the patient.”
There is substantial research evidence that MI does work, particularly for addressing substance abuse, Suzuki reported.
Yet there is no assurance that it will change a patient’s behavior, Delos Reyes emphasized.
“It cannot really address the profound and devastating cravings for opioids that we see in some of our patients who are severely dependent on prescription pills or heroin,” Levounis stated. “That is where we absolutely need to use pharmacotherapy…. That being said, MI is a wonderful adjunct to the treatment of opioid dependence with medication.”
And deploying MI can present other challenges—for example, making sure that it is being done correctly, Delos Reyes remarked, “because a lot of people hear a lecture on MI or see a videotape of it and say, ‘Oh yeah, I already knew that,’ when in fact they don’t.”
But even if a clinician knows how to conduct MI correctly, “what is challenging and not really clear is, how do you apply these skills to somebody who is very depressed, or very anxious, or has significant personality issues, or somebody who is psychotic or manic?,” Suzuki observed. “This is an area where people are conducting research and where MI skills may need some adaptation.”
Yet taking both the pluses and minuses of MI into consideration, those psychiatrists who use it tend to be very enthusiastic about it.
“I use it with patients in consultation-liaison settings,” said Suzuki. “I can’t imagine practicing without it.”
“I find it most helpful when patients using substances are ambivalent about coming in for treatment,” Marienfeld-Calderon indicated.
One of the advantages of MI, said Arnaout, is that “we therapists no longer have to cling to the illusion that we can control other people. As a result, we can relax and carry on a dialogue with patients rather than try to convince them to do something.”
“All psychiatrists should have at least some basic training in MI,” Delos Reyes suggested. “After all, many, if not all, of us, in psychiatry help ambivalent people change their behavior.”
“Psychiatrists who have been trained in CBT will find that MI adds to the skill set that they already have and especially for patients in pre-contemplation and contemplation stages of change,” Levounis advised.
More information about MI is posted at www.motivationalinterviewing.org and www.motivationalinterview.org and in the Handbook of Motivation and Change, edited by Levounis and Arnaout and published by American Psychiatric Publishing. APA members can order the book at a discount at www.appi.org/SearchCenter/Pages/SearchDetail.aspx?ItemID=62370.
Motivational interviewing (MI) is based on humanistic psychology, particularly the work of Carl Rogers, Ph.D., and was partially developed by psychologists William Miller, Ph.D., and Stephen Rollnick, Ph.D., explained Bachaar Arnaout, M.D., in an interview with Psychiatric News. Arnaout, an assistant clinical professor of psychiatry at Yale University, became interested in MI during his psychiatry residency, he said—“first by reading Miller and Rollnick’s book Motivational Interviewing and then being a therapist in an MI study.”
“I got introduced to MI in 2001 during my addiction psychiatry fellowship training,” Christina Delos Reyes, M.D., said. She is chief clinical officer of the Alcohol, Drug Addiction, and Mental Health Services Board of Cuyahoga County, Ohio. “So I’ve known about MI for years. But it has only been during the last five years that I have actually become part of the Motivational Interviewing Network of Trainers [thanks to training by]…the Center for Evidence-Based Practices at Case Western Reserve University.”
Petros Levounis, M.D., director of the Addiction Institute of New York, was also first introduced to MI during an addiction psychiatry fellowship. “It was becoming more and more obvious to me that confronting patients about their substance problems was doing more harm than good,” he said. “MI was a breath of fresh air from this more traditional approach.”
“When I was first exposed to MI during residency it didn’t resonate particularly with me because I was all excited about psychodynamic psychotherapy, cognitive-behavioral therapy, family therapy, and so on,” Joji Suzuki, M.D., a psychiatry instructor at Harvard Medical School, recalled. “It took me a while before I appreciated the effectiveness of MI, and it really wasn’t until I finished my addiction fellowship that I started practicing it.”
Psychiatrists who use motivational interviewing say that it is relatively easy to learn but takes time and practice to master.
“If you were to ask some experts on MI, they might tell you that it is a very difficult therapy to teach,” Petros Levounis, M.D., director of the Addiction Institute of New York, said. “But I have found that the basic principles, maybe not all of the techniques, of MI are rather easily taught and assimilated.” By way of example, he reported that two years ago, he and his colleagues decided to train all of their 220 staff members—the nursing staff, administrative staff, secretaries, security guards, van drivers, and even the cooks—in MI techniques. At the end of the training, all had learned enough MI to use it informally in their dealings with patients who came to the institute, he said.
True, “the concepts of MI are simple and easy to learn,” acknowledged Christina Delos Reyes, M.D., chief clinical officer of the Alcohol, Drug Addiction, and Mental Health Services Board of Cuyahoga County, Ohio. But, she stressed, “it takes a lifetime to hone the skills.”
Joji Suzuki, M.D., a psychiatry instructor at Harvard Medical School, shares a similar view: “Learning about MI is relatively simple. However, becoming proficient at it is far more challenging.” When he works as an MI trainer, he said, “I am careful not to portray MI as something clinicians can learn in just a few sessions or even in a two-day workshop.”