How do you motivate?

[loveoforganic]

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Statistics regarding smoking, obesity, etc. indicate to me that education (about the disorder, risks, etc.) alone is only a moderate motivator. So, for those of you who feel a responsibility to do more than that, how do you motivate your patients (to do whatever it is you want, e.g. compliance with medication)?

 

[OldPsychDoc]

Statistics regarding smoking, obesity, etc. indicate to me that education (about the disorder, risks, etc.) alone is only a moderate motivator. So, for those of you who feel a responsibility to do more than that, how do you motivate your patients (to do whatever it is you want, e.g. compliance with medication)?

Read these books and get training in this approach.

Bottom line is, YOU don't motivate. You help THEM find THEIR reasons to change and then offer the tools you have to help them get there.

 

[billypilgrim37]

Motivational Interviewing, Second Edition: Preparing People for Change

 

[loveoforganic]

Thank you both for your replies. I looked through the first few pages of that book online and it looks interesting - considering buying and reading over the summer. Would you say the theory covered extends beyond healthcare? I'm very interested in the concept as pertaining to healthcare, but would be interested in applying it as a teacher. My ability to actually apply it to healthcare wouldn't come for some time.

Thanks again.

 

[OldPsychDoc]

Thank you both for your replies. I looked through the first few pages of that book online and it looks interesting - considering buying and reading over the summer. Would you say the theory covered extends beyond healthcare? I'm very interested in the concept as pertaining to healthcare, but would be interested in applying it as a teacher. My ability to actually apply it to healthcare wouldn't come for some time.

Thanks again.

I (and the authors) would agree it is generalizable outside of healthcare -- it is in fact based on social psychological theories about Stages of Change, and is an application of that broader theory to health-related domains.

 

[loveoforganic]

Thank you very much 🙂

 

[nancysinatra]

Caveat to this post: I don't know too much about motivational interviewing, except that it is a type of interviewing, and isn't it associated with substance abuse treatment? Now I'm wondering--do PCPs get training in this, so they can use it to address smoking, obesity, exercise, etc? I thought it was classified as psychotherapy so my guess is no...

Does the patient need to start out with some motivation or can you start from zero? I wouldn't go out on a limb with this theory but one thing that makes psych patients unique is they don't really present for well patient visits, unlike primary care patients. Also PCPs follow multiple systems which is why they catch things like smoking, when the patient may only care about their knee pain. Psych patients don't come in unless they want to change something about themselves, however much they may actually resist doing so. So although I hate to say psych patients are "motivated" (many are not--many are self defeating even...)--I would think you could try to reach the patient at the level where they want to change, whereas with PC patients, they may have zero motivation to change at all, yet they come to the doctor reliably and take their meds. That's the puzzling thing--people with intact capacity, normal mental status, who yet are damaging themselves with bad habits!

Is there something out there that can help move a person from zero to 0.1 motivation on issues like exercise, smoking, etc? Can MI do that?

In any case this would have been helpful to me earlier today with my 350 pound smoker s/p hemorrhagic stroke now with TIAs and chest pain, who know he should quit smoking and walk more but won't even give a smoking cessation class a try!

 

[OldPsychDoc]

Caveat to this post: I don't know too much about motivational interviewing, except that it is a type of interviewing, and isn't it associated with substance abuse treatment? Now I'm wondering--do PCPs get training in this, so they can use it to address smoking, obesity, exercise, etc? I thought it was classified as psychotherapy so my guess is no...

Does the patient need to start out with some motivation or can you start from zero? I wouldn't go out on a limb with this theory but one thing that makes psych patients unique is they don't really present for well patient visits, unlike primary care patients. Also PCPs follow multiple systems which is why they catch things like smoking, when the patient may only care about their knee pain. Psych patients don't come in unless they want to change something about themselves, however much they may actually resist doing so. So although I hate to say psych patients are "motivated" (many are not--many are self defeating even...)--I would think you could try to reach the patient at the level where they want to change, whereas with PC patients, they may have zero motivation to change at all, yet they come to the doctor reliably and take their meds. That's the puzzling thing--people with intact capacity, normal mental status, who yet are damaging themselves with bad habits!

Is there something out there that can help move a person from zero to 0.1 motivation on issues like exercise, smoking, etc? Can MI do that?

In any case this would have been helpful to me earlier today with my 350 pound smoker s/p hemorrhagic stroke now with TIAs and chest pain, who know he should quit smoking and walk more but won't even give a smoking cessation class a try!

Too big to answer briefly, but yes--you can apply it to all of the above.
Many FP programs do teach a Stages of Change model similar to MI. It has been getting more acceptance in the CD field, especially as the confrontational/"intervention" model has often been found to do more harm than good.

Nobody has truly "zero" motivation. People stay in bad habits because they have reasons to, just as they change because they have reasons to. Their reasons to stay in the status quo may outweigh the reasons to change at the present moment, but in theory, identifying both the reasons not to change, allowing the patient to verbalize them, and identifying the reasons to change, and again getting the patient to express these themselves, in their own words, can get the process started. They may leave the appointment moving from 0.01 to 0.02, and they may lapse back to 0.001 10 minutes after they leave--but they'll know that you're going to be talking to them about it again and again...

With your 350# impending CVA guy, a motivational interview might ask why he enjoys smoking, what he gets out of it, what else is important to him, what things can HE come up with that might be improved in his life if he weren't smoking, what things work for him instead of lighting up at a given time, etc. "Trying a smoking cessation class" might be too large a commitment. Talking with you about what is important to him and what he gains by smoking less, then eventually quitting, can be rewarding in itself. It also lets you find interventions that are targeted to him directly.

 

[Red Beard]

Caveat to this post: I don't know too much about motivational interviewing, except that it is a type of interviewing, and isn't it associated with substance abuse treatment? Now I'm wondering--do PCPs get training in this, so they can use it to address smoking, obesity, exercise, etc? I thought it was classified as psychotherapy so my guess is no...

Does the patient need to start out with some motivation or can you start from zero? I wouldn't go out on a limb with this theory but one thing that makes psych patients unique is they don't really present for well patient visits, unlike primary care patients. Also PCPs follow multiple systems which is why they catch things like smoking, when the patient may only care about their knee pain. Psych patients don't come in unless they want to change something about themselves, however much they may actually resist doing so. So although I hate to say psych patients are "motivated" (many are not--many are self defeating even...)--I would think you could try to reach the patient at the level where they want to change, whereas with PC patients, they may have zero motivation to change at all, yet they come to the doctor reliably and take their meds. That's the puzzling thing--people with intact capacity, normal mental status, who yet are damaging themselves with bad habits!

Is there something out there that can help move a person from zero to 0.1 motivation on issues like exercise, smoking, etc? Can MI do that?

In any case this would have been helpful to me earlier today with my 350 pound smoker s/p hemorrhagic stroke now with TIAs and chest pain, who know he should quit smoking and walk more but won't even give a smoking cessation class a try!

For what it is worth, my introduction to motivational interviewing came at a 3 day series given at medicine morning report. Although it was obvious that most in attendance were like "whatever, this will never work, we don't have time for this, etc."

The guy presenting (a psychiatrist) showed some data to back its efficacy, don't recall exactly what it was but remember that it was convincing at the time.

 

[VMSmith]

I once used some motivational techniques during rounds with a medicine night float admission regarding his medication noncompliance. Or nonadherence. Whatever.

The attending recognized what I was doing and commented about it afterward - he said he uses motivational interviewing regularly with his clinic patients and recommended the medicine residents learn about and try it out with theirs.

It's a good technique that can be applied just about anywhere in medicine if you put in the time and effort to do it.

 

[Therapist4Chnge]

Motivational Interviewing can be a very useful skill to possess, and the literature supports its use in a healthcare setting. I've lectured and presented on MI to a range of professionals, and found the best response to be from the people who had some existing knowledge in the area because they were able to ask more integrative questions about it. I would caution trying to do it without having a firm grasp because you could cause the opposite effect if the patient

A good intro text will get you the basics, and then some mentorship should solidify the information. Attending a CME on the topic may provide some good basic information, it seems to be a popular topic now. There is a certain style to it, but if you get it down, you can really see some gains in patient compliance. I have seen some pretty good results from using MI for smoking cessation and DM, but I've heard of GPs/FPs using it for general health issues. It is also a great way to build some quick rapport and identify where the patient is in their stages of change, which can help you formulate a more effective intervention.

 

[Psychelle]

I really hope to learn more about this technique, either as part of residency training or on my own. We touched on it briefly during intro to clinical medicine classes, and more extensively in regards to helping patients quit smoking on my family medicine rotation.

Personally I wish we'd spent a whole lot more time learning about stuff like that and less on the biochemical pathways of a random gene in generations of mouse models but... that's just me. 😛