BELLEVUE, WASH. – Motivational interviewing techniques aren’t just a method for getting adolescents to pursue positive changes, but are a balm for the frayed nerves of physicians and parents, according to Dr. Cora C. Breuner.
A physician talking to an adolescent about, say, the dangers of smoking may be tense and frustrated because it seems impossible to connect with the teenager, who doesn’t like the direction of the discussion. If a parent is present, he or she is tense and frustrated too because the doctor doesn’t seem to be reaching the teen, Dr. Breuner added.
The problem usually is that the adolescent is in the early steps of motivation to change, but the physician and parents want action.
"You can’t get someone to go there without going through the previous steps. It’s impossible," said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle. "There’s a huge disconnect between what we want to do and what they want to do," she said at the annual meeting of the North Pacific Pediatric Society.
The foundation of motivational interviewing is that change is not imposed, but elicited from the client. It’s the teenager’s task, not the counselor’s, to articulate and resolve his or her ambivalence, with the counselor’s directive assistance. The therapeutic relationship is more like a partnership or companionship than an expert/nonexpert dichotomy.
A good way to start is by talking about ambivalence, a word that adolescents love once you explain what it means. Dr. Breuner describes it as, "You’re kind of not sure. You feel two feelings, and it’s kind of crazy. You feel one thing and you think the other." That usually clicks with teenagers "because that’s their life, really," she said.
When discussing a problem behavior with an adolescent patient, she said she always writes the five stages of motivation to change on the white board in her office and describes them:
1. Precontemplation. This stage is also known as denial. The teenager may be thinking, "I don’t have a problem. You’re crazy. I’ve been smoking a long time. It’s no big deal. Everybody smokes. My mom and dad smoke."
2. Contemplation. "Maybe I have a problem, but I don’t want to do anything about it."
3. Preparation. "I have a problem and I want to do something about it, but not now. Maybe in a month."
4. Action. "I want to do something about it now. I need to stop doing this."
5. Maintenance or prevention of relapse. "How do I keep not smoking when all of my friends do?" (Or, depending on the problem, "How do I not drink when everybody around me drinks all the time? How do I stop spending so much time on the Internet, or so much time exercising, or talking, or working so hard?")
Dr. Breuner said she writes the stages on the board and asks the patient, "Where do you think you are?" Adolescents’ eyes go from glazed to engaged, and they always circle either "precontemplation" or "contemplation." Physicians and parents recognize that they are at "action."
The tension in the room instantly eases, she said. The physician and parent calm down because they’re no longer obsessing that the teenager will never listen to them. They’re now trying to understand the teen’s frame of reference and reinforce the teen’s motivation.
Dr. Breuner said she then breaks down the stage that the teen circled into a scale of 1-10. If a patient is in denial about smoking being a problem, that’s a 10 and the next stage, "contemplation," would be a 1. Dr. Breuner asks the patient where on that scale he or she fits in. If the adolescent picks, say, 8, Dr. Breuner asks what it might take to get the teen to be a 7.
The patient may say, "Tell me a little bit more about why it’s bad to be a smoker" (or bad to eat too much, or to exercise too little, or to keep his or her phone by the bed). Dr. Breuner provides some quick information in a nonjudgmental tone and ends with, "Come back and we’ll talk a little more about that."
Early follow-up is extremely important for motivational interviewing. Don’t wait 6 months for a follow-up visit, she said. Monitor the teen’s degree of readiness to change, but don’t jump ahead. Express acceptance of where the patient is in the stages, and affirm his or her freedom of choice and self-direction.
"Just try that. It’s so cool, because it works every time" to ease tensions in guiding the adolescent toward change, she said.