In the first part of an appointment, encourage your patient to explore the effects of their medications and other clinical issues. During the remainder of the meeting, determine a "target" of change.
Proper technique, practiced over time, can transform an appointment from "medication management" into a serious change in behavior, as evidenced by the 5 example dialogues. These surround a conversation with patient with psychosis, but the examples can serve as a prototype for other issues.
Changing behaviors in 5 conversation styles. Read the captions for sample scripts.
Patient: I don’t want to take my medication. It makes me fat.
Psychiatrist: You don’t like that the medication makes you gain weight.
Psychiatrist: What’s your biggest concern about weight gain?
Patient: That I won’t look the same.
Psychiatrist: It’s important to you that you look and feel the same as much as possible. I wonder if it would helpful for us to talk about some ways other patients on antipsychotic medications manage their weight?
Psychiatrist: You have done such a great job managing your medication. I wonder if it would be ok to talk about an area that’s not so easy to manage, like your smoking.
Patient: No, no, this is not a good time. Things are tough at home.
Psychiatrist: Okay, you are doing all that you can do right now by taking your medication. It’s too much to think about quitting smoking until things are better at home. Maybe I will check in with you about this at a later visit?
Psychiatrist: It sounds like it has been hard for you to stick to your goal of walking 2-3 times a week.
Patient: Yes, lots of times I just don’t feel like it.
Psychiatrist: It’s hard to get motivated.
Psychiatrist: So, it’s hard to get motivated and you end up not walking like you had planned. I also heard you say that when you do walk, you feel more motivated and energetic afterwards.
Patient: That’s true. It’s just hard to get started.
Psychiatrist: That lack of motivation makes it hard to get started, but once you do, you feel a whole lot better, and that’s one of the reasons why you keep trying. What other reasons are there?
Psychiatrist: Can we talk about how you have been feeling on this medication from the inpatient unit?
Patient: You aren’t going to make me go back there are you?
Psychiatrist: You are anxious that you might go back there. What was your experience like there?
Psychiatrist: You felt like the therapists were there to trap you. You felt like they weren’t listening to you. What do you think about telling me when you feel cornered or not listened to?
Patient: Maybe. I don’t know what good it will do.
Psychiatrist: It’s hard for you to feel safe.
Patient: I don’t want to be locked up again.
Psychiatrist: Right. You want to be well and to keep yourself out of that place. I want to help you manage your symptoms so you don’t have to go back. Would it be ok if we talked about what has been working for you?
Patient: I need to lose some weight. The doctor told me I’m at risk for diabetes.
Psychiatrist: You want to better manage your weight in order to reduce your health risks, because your medical team wishes this for your health, and to feel better.
Patient: Yeah, it’s time that I work on this. For me and my kids.
Psychiatrist: You have a few reasons you want to lose weight. Your health and to be here longer for your children. Sounds like you have been thinking a good deal about this. Any ideas for where you might start?
Patient: Well, I think about starting and then I remember how hard exercise is.
Psychiatrist: While you are reminded of the challenges of weight loss, you haven’t let the idea go.
Patient: Yeah. You are right. Where should I start?
Psychiatrist: Is that something you’d like to talk about today?
Patient: Yes, I think I could start small.
With motivational interviewing, clinicians can build and refine a therapeutic alliance with a patient who may be struggling with psychosis or other psychiatric disorders.