Dr. Erica Lander Miller on Motivational Interviewing
For Resistant Anxiety Disorder Patients
By Lynn Mollick
On Sunday, June 22 Dr. Erica Lander Miller spoke to NJ-ACT members on Motivational Interviewing for patients with anxiety disorders. She advised listening carefully to assess patients’ motivation for change. Consider an OCD patient with a handwashing compulsion:
1. Sustain talk. “Washing my hands makes me feel clean.”
2. Change talk. “I really need to stop washing my hands so much.”
3. Commitment talk. “I will delay washing my hands for five minutes and see how anxious I become.”
Dr. Lander pointed out that many anxiety patients enter treatment with ambivalent feelings about therapy and about changing. If CBT is begun too soon, especially if exposure is begun too soon, this can cause patients to avoid homework assignments and terminate treatment.
Adding Motivational Interviewing (MI) to traditional CBT for anxiety disorders
helps therapists employ techniques when they are most likely to be effective, i.e. when patients are willing to undertake the time-consuming and sometimes uncomfortable work of expopsure and other CBT techniques.
According to MI, commitment to change ebbs and flows during treatment and patients will not always be moving forward, consistently implementing CBT techniques. Life sometimes interferes with therapy. Ambivalence about change is to be expected. Calling failure to change “resistance” blames the patient for a frequent and understandable phenomenon.
To help patients resolve ambivalence and become more committed to change, engage them in a conversation that draws out their unique reasons to change. What are the benefits of changing? But what will be lost by changing? Remember that bad habits persist for a reason. But on the other hand, what will happen if the patient does not change?
Partnership and collaboration are central concepts in MI. Reflection and open-ended questions are often more helpful than advice. Therapists should not try to motivate patients to change. Instead therapists should listen and draw out patients’ motivation. Trying too hard to change patients creates “reactance” -- resistance to change.
Therapists should also listen for “Discord Talk,” statements that indicate the patient feels misunderstood. Example: “You don’t know how important it is to feel clean before I touch anything that my child touches.” MI views Discord Talk as inevitable.
According to MI, treatment moves back and forth through 4 stages which require different therapeutic interventions:
1) Engaging – Involve the patient in discussion about their problem and develop a trusting relationship. Find a gentle way to define the problem that speaks to the patients’ concerns. Dr. Lander Miller gave the example of describing binge drinking to sorority girls in terms of the number of calories consumed during a binge.
2) Focusing – Narrow the focus of discussion to problems that the patient might want to change. Find out what’s important to the patient and suggest what the therapist might do to help.
3) Evoking –Why does the patient want to change? What are the patient’s goals? Be optimistic about the patient’s ability to change. But also find out why the patient wants to remain the same.
4) Planning – What steps will the patient take now? This is the stage when you do CBT, after engaging, focusing, and evoking. Let patients suggest their homework and determine the pace of change. “What are you ready to do now?” is a question that guides rather than directs.
When patients are not ready for CBT, it’s helpful to highlight the discrepancy between where they are and where they want to be. Ask them to rate how important it is for them to change right now, and then ask “Why is changing somewhat important to you right now instead of very important?” “What would have to be different for change to become very important?”
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