Doctor-Patient Communication
Liz Sutherland, ND, teaching
Our assignment was to read a couple of papers--- The use of brief internentions adapted from motivational interviewing across behavioral domains: a systematic review and Brief Intervention for Heavy-Drinking College Students: 4-Year Follow-Up and Natural History and to answer the questions that appear below.
1a) The Dunn paper found that Motivational Interviewing (MI) appears to be more effective in improving substance abuse/dependency behaviors and less effective for instilling successful weight loss behaviors in obese women. What factors (such as population, nature of behavior) do you think influence the effectiveness of MI as an intervention? Do you see any ways its effectiveness might be improved?
Lots of things influence the efficacy of an attempt to awaken a person’s own motivations to behave differently. It appears from the reading that MI has proven effective at long term reduction of binge drinking with intervention occurring during college, among relatively young drinkers. Whereas a four year followup might appear long term, that timeframe seems different when applied to youthful drinking as opposed to the reality of obese women who may have been overweight for many times four years. It appears to me that younger people might be more receptive to re-evaluating their own behaviors and resistances than older ones, and also from these examples that just might be considerably easier to stop binge drinking than it is to loose 100 pounds. So age and the entrenchedness (new word) of the behavior appear to be factors. These two factors probably relate directly to the individual’s readiness.
On ways to improve the effectiveness of MI, it seems that this method of communication might be broadly taught among not just healthcare practitioners but also teachers, clerics, parents, scout leaders and all people who have the occasion to teach or advise others. Perhaps at the social level we would have the highest results if individuals with challenges had an entire social network helping them to process their own ambivalence, realize the discrepancy between their ideals and their actions, and begin to acknowledge their own ability to adjust behavior.
1b) Why might different studies of MI show different results?
Lots of reasons. Different populations were considered with risk factors ranging from unprotected sex to drug use to heart problems or diabetes. The people intervening with MI had all different levels of training, and also different approaches---on paper, over the phone, in person, different durations and regularity of meetings, and other variables. There were so many variables in the studies compared by the systematic review that it is not surprising that they found little to conclusively report.
1c) What is the advantage to having a systematic review of MI, as opposed to reading individual articles?
The advantage would be that that we begin to get a sense of the range of applications and potentially to have an overview that could help us to assess where the technique might be more or less effective.
2) In the context of what we have talked about in class regarding doctor-patient interaction, how does MI or Brief Intervention fit with your world view? Are they useful techniques? What are the limitations, the strengths? Do you think they truly involve being careful, respectful, listening and present?
MI fits beautifully with my world view and with my training in NonViolent Communication. In fact I find MI to be remarkably similar to Marshall Rosenberg’s approach, and I wonder if there might have been some cross pollination among psychologists prior to the publishing of Miller’s first paper on MI in 1982. MI fits because I believe that one can best relate to another by avoiding judgment. Therapeutic advice may best be given by allowing the patient’s own discomfort and self knowledge to rise to the surface. So yes, I find MI useful. The strength is in the totality of the shift, should it occur. When a person talks themselves into making a change, I believe it is much more likely to stick than any change that they make due to external pressures.
The greatest limitation that I can currently see is that if the patient is not ready, it does not appear to generate readiness, and if the patient does not feel able, it does not appear to increase self efficacy. The effort is there to increase both readiness and self-efficacy, but I am not sure the method actually accomplishes this. I think that the populations among whom MI has worked the best are the ones for whom those two factors were already leading them toward awareness and behavior change.
I think that with enough role playing and practice, a person who was not actually caring might be able to pretend caring, a person who was not actually respectful might be able to pretend respect. But listening and presence cannot be faked. Everyone knows if they are really being listened to, or not. You cannot really listen if you are not present, so presence is the fundamental prerequisite for practicing MI. That and remaining nonjudgmental. This brings up another weakness of the method, and that is that it does require a high level of awareness of the practitioner. Not everyone who might think that they can effectively practice MI will actually be able to do it. It is not as easy as it sounds. The human condition is to be ambivalent.
3) Think about MI as one possible communication technique. If you were going to integrate that technique into your practice, how would you go about using it with patients? What do you think would be needed at the individual level, the practice level, and the community level?
I aspire to remain in the mode of presence and nonjudgment with my patients at all times, and so MI will be integrated at that level immediately and permanently. I will seek out additional readings and trainings on the rest of the practice, and as it becomes second nature to me I will certainly employ it. It will be necessary for me to practice at avoiding and de-escalating resistance. Though I see that this is desireable, I often find myself beating on the wall of someone’s denial in my personal life, and so I may attempt it in medical practice as well. This is part of my own growth and awareness project. All three of the levels mentioned (individual, practice, community) require the same fundamentals, as far as I can see. I would like to see these concepts and trainings integrated at a cultural level and so I will continue to teach them when I find teachable moments, and to apply the principles whenever I find dissonance between belief and practice.