Dr. Rosengren: At its most basic, it is a conversation in which you are trying to help someone deal with ambivalence that prevents them from acting on a problematic behavior. It’s really about helping them sort through this ambivalence and come to a decision that makes sense within their framework. At a more complex level, it has to do with things like paying attention to how the patient talks and what kind of language they’re using. It also involves responding differentially—giving less attention to certain kinds of language and more to others—in the service of helping them work through ambivalence.
CATR: So we have a patient who is doing something unhealthy and they come to us for help. But oftentimes they are not certain that they’re ready to give that up, correct?
Dr. Rosengren: Right. There’s something going on, and they want whatever is bothering them to go away. But it doesn’t necessarily mean that they’re ready to make a change. When I first got into the addiction field, one of my mentors would say, “When people come into treatment, they are ready to give up the consequences of the alcohol or drug use, but not the drug itself.”
CATR: So how do we get into that conversation?
Dr. Rosengren: According to the latest edition of Miller and Rollnick’s book, Motivational Interviewing, there are four processes to think about as we are talking with our patients: engaging, focusing, evoking, and planning (Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York, NY: Guilford Press; 2012). Starting with engaging is important because this is where we form the connection with patients so they feel they are in a safe place where they can talk about what’s going on in their lives.
CATR: I think most psychiatrists would feel fairly comfortable with the need for engaging and forming an alliance. A patient will come in, and before jumping into asking about symptoms we’re going to say, “How have you been doing; what have you been up to?” etc.
Dr. Rosengren: Yes, but I would add one thing: It’s important to open those conversations with a positive focus. When patients come in and we start asking questions about what’s been happening, what problems have you had since I saw you last, we’re asking people to talk about the negative. If we start with positive things, it opens them up, broadens their focus, elicits positive emotions, and also makes them more willing to talk about areas that aren’t going so well. So what I do with folks is ask about what’s been going well since I saw them last. “Where have you felt successful? Tell me about a time where you experienced happiness, joy, or a moment of awe.” It doesn’t have to be anything big. “What made you smile in the last 24 hours?” Now if somebody’s got chronic depression, that may not be the best question, but then you might start with, “When did you feel a moment of contentment in the last week?”
CATR: Interesting. So we can really be very explicit and say, “I’d like to start today with some of the positives. Tell me about something that you enjoyed since we last talked.” And they may tell you about a great meal that they had or that their baseball team won a big game. How significant is it to bring that kind of positive energy into the mix?