Motivational Interviewing in action
Previously, I introduced you to the Stages of Change derived from a style of counseling called Motivational Interviewing. I invited you to examine the qualities of each stage to and discover your own readiness for change. This time, we will examine the limitations of medical doctors to address this issue and build a rationale for hiring a therapist as part of your migraine treatment team.
Ideally doctors focus on helping patients make the move from one stage to the next rather than trying to force change all at once. Unfortunately, even for the trained professional, it is easy to get ahead of the patient.
Doctors don’t have training in psychotherapy, so they don’t always know how to communicate with patients who are not ready to actually make the change he or she wants. Some don't even stop to ask what a patient thinks he or she is ready to do, what the barriers are, or what has already been tried. So, when a patient continues to be symptomatic despite exhausting all interventions, these doctors reach for the fallback, psychotherapy. Unfortunately, the delivery often gets garbled. What patients hear is that their symptoms must be psychological (i.e. “You are making it up” or “You’re crazy”), their doctor blames them, or the doctor is giving up on them. All of these messages are incredibly invalidating. Invalidation has a tendency to trigger negative emotions that interfere with the impulse to change.
The readiness to make change is something best addressed with psychotherapy. That is likely why a doctor will make the referral. It’s the delivery that’s the problem. Ideally, a discussion about behavior change would go like this:
Doctor: Of all the lifestyle changes I have suggested, which one do you feel most ready to do?
Patient:I could probably think about keeping a headache diary.
Doctor: Okay, that’s great. So on a scale of 1 to 10 with 1 being “not even thinking about it” and 10 being “actively making the change” where do you think you fall for this change?
Patient:I’m probably about a 6. I want to do it, but I’m afraid I won’t be able to keep it up.
Doctor: Awesome. Thank you so much for you honesty. What do you think it would take to move you from a 6 to a 7?
Patient:I guess I would need to find a simple way to track my migraines even when I am away from home.
Doctor: What has kept you from taking that step before?
Patient:I haven’t found anything that really works. Something I have to write down gets left behind. If I use something electronic, I’m stuck to my computer. I haven’t found a phone app that suits my needs either.
Doctor: Is that still a barrier?
Patient:Yeah, kind of.
Doctor: When you are ready, how might you overcome that barrier?
Patient:I just need to get more serious about finding something that works.
Doctor: What one thing do you think you are willing and able to do before our next appointment that will help you make progress going from 6 to 7?
Patient:I could download an app and try it out for a week or so.
In this scenario, did the patient agree to keep a diary? Not really. She agreed to try to find a way to track her migraines for a week. That’s not a permanent change, just a “baby step” in the right direction. I would typically follow this up with questions about what might get in the way of this planned behavior, how to overcome barriers, and the importance of open communication even if it’s something she doesn’t think I will like to hear.
Even if she finds the perfect solution, she still has to learn how to make that a permanent habit. Over time, she will succeed, fail, give up, complain about why it failed, convince herself it’s not really necessary, reconsider trying again, make a new plan, and give it another try. Over and over again, this patient will try to develop the habit of keeping a migraine diary. It will take several rounds through these stages of change before keeping a diary becomes a permanent change.
This kind of process can take a very long time as you work on making changes one at a time over many months. Therapists, counselors, social workers, and psychologist are trained to work with patients over a lengthy period. The slow pace is expected and encouraged. That’s one reason why patients get referred for therapy. Doctors just don't have that kind of time.
All of this is completely normal. You are not a failure if you cannot make every change your doctor wants all at once. You are quite human. So cut yourself a break and remind yourself that you are doing the best you can with what you have.
Challenge: Think of one small change. On that same 1 to 10 scale of change, where do you think you fall? What would it take to move you from that number to the next? I think you can take it from there.
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