Michael S. Jellinek, M.D., Schuyler W. Henderson, M.D., M.P.H. Assistant Editors
Motivational Interviewing and Adolescent Psychopharmacology JOHN J. DILALLO, M.D.,
In the comprehensive mental health care of an adolescent, psychiatric medication often plays a vital role in addressing debilitating symptoms and improving social functioning. However, although estimates specific to adolescents are limited, psychiatric patients frequently do not adhere to prescribed medications over time.1 In turn, medication nonadherence predicts psychiatric hospitalization, treatment failure, and other poor outcomes.2 A growing literature attests to the quality of the therapeutic alliance as a central influence on patient adherence to psychiatric medication and other recommended therapies.3Y5 A prescription’s effectiveness can depend significantly on the relationship in which it is made. Descriptions of effective Bpsychopharmacotherapy[ with children and adolescents emphasize forming empathic alliances with both patients and parents, early introduction of medication as a possible treatment option, assessment of family, school and social contexts, promoting self-acceptance and hope for the future, and ongoing attention to the particular meanings assigned to medication by the developing child.6Y8 Such descrip-
Clinical Perspectives aims to provide a venue for exploring topics of importance to child and adolescent psychiatry, fostering discussion of these issues, educating child and adolescent psychiatrists and the broader medical community, and bridging clinical practice and research. Where applicable, appropriate permissions for publication were obtained from the patient(s). Accepted September 6, 2008. Drs. DiLallo and Weiss are with the Child and Family Institute, Department of Psychiatry at St. Luke’s and Roosevelt Hospitals and Columbia University. The authors thank Daniel Medeiros, M.D., and Ramon Solhkhah, M.D., for their moral support of the project. Correspondence to John DiLallo, M.D., Office of Child and Family Health, NYC Children’s Services, 150 Williams Street, 14th Floor, New York, NY 10038; e-mail: [email protected]
0890-8567/09/4802-0108Ó2009 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/CHI.0b013e3181930660
GONY WEISS, M.D.
tions highlight the importance of devoting adequate time with patients and families to these psychosocial aspects of prescribing medication. Likewise, some warn that patients’ wishes for quick gratification, Bheroic[ physician tendencies, and economic factors such as brief Bmedcheck[ appointments may limit medication treatment effectiveness and promote polypharmacy.7,8 Motivational interviewing (MI) is an efficient and collaborative style of clinical interaction that can boost the effectiveness of the therapeutic alliance by enhancing three major elements: empathy that is accurate to the patient’s experience, patient confidence in his or her ability to improve, and positive expectations regarding the recommended treatment. This clinical perspective will describe the use of MI strategies in the practice of adolescent psychopharmacology. Among patients in our academic day program, MI has appeared anecdotally to increase adherence to medication and to strengthen participation in other treatment components. Furthermore, by fostering autonomy and personal insight, MI has helped our adolescent patients to integrate their psychiatric difficulties into a more independent and resilient identity. MI, AMBIVALENCE, AND ADOLESCENT IDENTITY DEVELOPMENT
Miller and Rollnick9 define MI as Ba client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.[ Based on the Stages of Change Model of Prochaska and DiClemente10 (Table 1), MI developed as a nonconfrontational approach to decreasing the harmful behaviors found in substance use disorders. Because of its effectiveness in adult populations, MI-based interventions for treating adolescents with substance use disorders have been promoted by the U.S. Government Substance Abuse and Mental Health Services
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TABLE 1 Motivational Interventions According to Stage of Change Patient’s Stage of Change
Clinician Intervention as Developed for Treatment of Substance Abuse
Increase awareness of consequences of substance use. Develop discrepancies and elicit ambivalence toward change. Harm reduction model entails acceptance and nonconfrontation. Amplify ambivalence. Roll with resistance. Increase confidence in ability to decrease substance use. Provide menu of treatment options. Negotiate a treatment plan, including biological, psychological, and social components. Obtain informed consent. Negotiate patient’s commitment to a full trial of selected treatment options. Reaffirm commitment. Track level of substance use and related behavior. Reinforce any harm reduction achieved. Encourage active problem solving using cognitive techniques. Revisit ambivalence as it arises. Revert to previous stage interventions if relapse occurs.
Administration.11 Beyond addictions, MI has been used to facilitate change in several health-related behaviors,12,13 including treatment adherence among adolescents with type 1 diabetes.14 Applying MI to general adolescent psychiatry requires that the behavioral impairments related to psychiatric disorders be reframed as impediments to self-realization and, therefore, as potential targets for change. Medication and other treatment options are viewed as practical tools that a patient may use to make a desired change happen. Importantly, the psychiatrist must regard the patient as the essential source of solutions to the problem behavior and as the only true expert in regard to what making change will entail. In practice, this perspective is no mere platitude but a principle that guides each step of the clinical process. Likewise it is the patient, not the clinician, who is ultimately responsible for any choices made in regard to change. Because the balance between adolescent autonomy and parental authority varies through development, parallel motivational interventions with parents or guardians are often useful, particularly when insight is limited. The essential tasks of the motivational psychiatrist are to elicit the pro-change components that exist already within a patient’s thinking and to promote their growth. In general, this process begins by guiding the patient in determining his or her personal goals, then exploring the discrepancies between where the patient is and
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Adaptations to Adolescent Psychopharmacology Develop discrepancy by eliciting patient’s personal goals and comparing with current functioning as affected by psychiatric symptoms. Early introduction of treatment options including medication. Instill realistic, positive expectations for medication and other therapies. Elicit patient’s rationale for taking a medication and the meanings this has for concept of self. Emphasize autonomy, safety, and benefit of adherence to full trials of medication and other therapies. Review medication response and adverse effects. Identify any factors affecting nonadherence. Develop Breminder rituals[ as needed. Review adherence, response, pros and cons of maintenance dosing, and meaning of long-term therapy for patient’s identity.
where he or she would like to be with respect to these. In adolescent day treatment, one common patient goal is the desire to complete high school and attend college. Most often, there is a discrepancy between the passing grades that academic success would require versus the poor school performance that results from psychiatrically impaired behavior. Highlighting such a discrepancy will most often elicit a discussion of the patient’s ambivalent attitudes, pro and con, toward making the behavior change that achieving the goal would require. Ambivalence contains the pro-change Bseeds[ of motivation, which can then be Bwatered[ using the MI techniques described below. This process sets the stage for the eventual introduction of medication and/or other treatment options to support the desired change that the patient has self-defined. The nonconfrontational stance of MI can be particularly effective in counseling adolescents, whose developmental needs may predispose ambivalence toward authoritative advice. Recall that the core psychological task of an adolescentVidentity formationVentails constructing an answer to the question: BWho am I?[ using the many sources of information and experience in his or her typically peer-centered milieu. Furthermore, at the cognitive level, adolescence marks the dawn of a person’s ability to generate abstract hypotheses, such that identity development may be viewed as a trial-and-error process of testing ideas about the self.
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Therefore, any information communicated to an adolescent about diagnosis or treatment options will be incorporated into his or her process of self-definition. Much resistance may be circumvented by first eliciting the patient’s particular understanding of his or her situation and validating this as experientially true. Table 2 compares MI with other communication styles useful in facilitating adolescents’ autonomous treatment decisions. Such communication can increase concordance15 of perspective between psychiatrist and patient, thus raising the likelihood of treatment adherence. MI AND THE STAGES OF CHANGE
The process of enhancing motivation cannot be forced. Rather it must begin by responding to patients Bwhere they are[ with respect to stage of readiness for change and choosing motivational techniques accordingly (Table 1), while keeping in mind that persons often fluctuate between the stages. In the examples below, we use quotes from adolescents with whom we have engaged in MI. A patient at the precontemplation stage has not yet consciously identified any reason for making change. BI already told them all that I don’t have a problem with anger, it’s just these other kids who get in my face![ At this stage, a patient may respond best to empathy for his or her experience, along with reminders that he or she is in control of treatment decisions. This patient
also can be guided toward self-exploration in terms of future concerns or personal goals. BYou seem to have good reasons to feel angry when other kids treat you like that. Has arguing back when they misbehave created any difficulties for you?[ Negative consequences and future risks of problem behaviors should be stated simply and directly, with continuing emphasis on the patient’s being in control. BSo yelling back at them sometimes gets you suspended. Do you think that this issue could affect your grades this semester?[ Effort should be made to leave the conversation open ended, so that it can continue in the future. BI understand that you don’t want to think right now about different ways that you might respond to those kids. It sounds like a tough situation, so I hope that we can talk more next time about how to change it in a way that will help you pass your classes.[ At the precontemplation stage, except in urgent situations, medication options are best mentioned only as part of a menu of possibilities for treatment in the event that a patient decides to make a change. BMost people find it helpful to have all the facts before they make a decision. Please let me know if at some point you want more information about medications and other therapies that could help you change this situation.[ Once a patient has reached the contemplation stage, targets for change have been established, and ambivalent attitudes can be elicited by exploring discrepancies
TABLE 2 Complementary Communication Styles in Adolescent Psychopharmacology Description Example
Psychoeducational Providing up-to-date medical information concerning diagnosis, prognosis, and treatment options for informed consent. Most often requires use of complementary approaches to be effective. Psychodynamic Eliciting the particular meanings of symptoms and proposed treatments as experienced by the patient, in the service of strengthening a working alliance. Cognitive therapy Reducing thought distortions and core schemata that feed negative affect and behavior in response to contextual events. Dialectical Nonjudgmental reinforcement of previously taught behavior therapy behavioral skills modules, intended to replace self-injurious and other lifestyle-interfering behaviors. Motivational Amplifying patient motivation for change by eliciting interviewing personal goals, fostering autonomy, and highlighting patient ambivalence toward taking necessary steps forward.
BPsychiatrists refer to the irritable moods that you and your family describe as bipolar disorderYtype 2. Mood stabilizing medications can help in reducing these mood swings.[ BWhy do you think the teachers keep blaming you when other kids come at you like that? What do you think taking a medication would say about you?[ BSo your thoughts tell you that trying this medication would mean giving in and letting others control you. How do you know those thoughts are accurate?[ BIt sounds like losing your temper was not an effective way of gaining the respect you want. What do you think got in the way of using your interpersonal effectiveness skills?[ BSo you want to learn to stand up for yourself without getting into fights, but you don’t want to try medication or psychotherapy. Would you like to hear some information about these options before you make a final decision?[
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between aspiration and performance. BI haven’t done homework for about 4 years, and there’s no way I am going to start now. Plus I’m really a night person, so I’m never going to wake up on time for school anyway.[ As with this patient, who wished to earn a high school diploma but had resumed a pattern of erratic sleep and school avoidance after stopping his medication, the psychiatrist can respond by highlighting discrepancies while simultaneously accepting and Brolling with[ the patient’s stated resistance to change. BYou can’t get that diploma without doing homework or coming to school on time, and we have seen that medication can help if you want to participate more in school. But you sound like your mind is really made up about these issues. Is there anything else I can help you with?[ Rolling with resistance can encourage pro-change arguments to arise from the patient and thereby circumvent resistance to direct advice. However, because ambivalence consists of two poles, further resistance is sure to follow, and so the process is repeated. Patient: BWell, I guess I will have to do that stuff if I’m going to graduate, won’t I? So maybe I should just drop out.[ Psychiatrist: BDropping out is certainly another option. Maybe that is what you will decide to do.[ Once a patient’s reasons for change outweigh the reasons not to change, he or she has entered the preparation stage. Here, the psychiatrist reinforces the patient’s decision to change by developing a treatment plan in which the target symptoms of medication and all treatment components are clearly understood. Motivation is maintained by reiterating the benefits of change. Environmental barriers to medication adherence frequently surface at this stage, whether financial, logistic, or attitudinal. BMy brother hates me. He told my grandma that I have to take medicine, and now she says that I shouldn’t because there is nothing wrong with me.[ Often, it is helpful to explore attitudes toward medication with family members and reframe them in terms of motivation for change, to educate the patient about personal privacy, and to identify appropriate social supports. During preparation or the subsequent action stage, ambivalence about the decision to change may resurface at any point. BI know the medication helps, but I hate feeling like I’m going to be like my dad because I take the same medicine that he does.[ As with this patient who had stopped her lithium, the psychiatrist can non-
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judgmentally acknowledge the patient’s inner conflict, then foster autonomy by reassigning her control of decisions. Within this renewed rapport, the process of determining goals and eliciting the pro-change components of the patient’s ambivalence starts again. MOTIVATIONAL STRATEGIES TO INCREASE TREATMENT ADHERENCE
Each of the three therapeutic elements previously mentionedVaccurate empathy, patient self-efficacy, and positive treatment expectationsVcan be enhanced through the use of the motivational strategies described here. The choice of strategy at a given point in treatment depends on the patient’s stage of readiness for change and on the specific content of the ambivalence uncovered. Motivational strategies promote the process of change. This process entails the overcoming of inertia, followed by the sustenance of momentum, until the point at which the change is congruent with the patient’s own notion of self. StrategiesVPart I: Building Rapport With OARS
To establish a rapport that will best elicit the patient’s inherent motivation, the motivational psychiatrist can use OARS: open-ended questions, affirmations, reflective listening, and summaries. Like oars in a rowboat, these techniques can generate momentum in the direction of change, and they can be applied whenever a clinical encounter gets Bstuck.[ Likewise, techniques to avoid are those likely to impede this momentum: yes/ no questions, confrontations, unsolicited advice, pejorative labeling, and any invalidation of patient autonomy in choosing how to respond to clinician input. Open-ended questions help to elicit what a patient or his/her parent wants from treatment. BWhat brings you here?[ BWhat sort of things might you want to work on?[ It is the clinician’s job to elicit the patient’s self-determined goals and to use them as the soil in which the patient’s motivation to change problem behaviors can take root. Open-ended questions also can explore the particular meanings that patients and families assign to psychiatric medications. BSo if you decided to take a medication, what would that say about you?[ Patients often interpret medication to mean that BI’m crazy,[ BI’m weak,[ or Bsomething [inalterable] is wrong with me.[ Adolescent patients or their parents also may view medication as punishment, as poison, as part of an
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ominous experiment in which the patient is a Bguinea pig,[ or as validation of the sick role. Once elicited, such meanings should be validated as experientially true (BIt makes perfect sense that it would feel that way[) and then reexamined in the motivational context of discrepancies between the patient’s current functioning and his or her long-term goals. In this new frame, medication becomes a potential source of help in making change, and the decision whether to take medication becomes more practical than philosophical. Affirmations are validating statements that encourage and amplify any shift in the direction of positive change. BI think you took a big step in trying the medication. Even though this one didn’t work for you, it shows that you’re serious about making things better.[ Such reinforcements must be sincere and simple to build patient confidence that change is possible. Reflection statements provide the patient the opportunity to clarify any misunderstanding of his or her perspective, as well as the sense that they have been heard. For the psychiatrist, reflections assure that the empathy provided to the patient is accurate with respect to his or her emotional experience. At the least intrusive level, reflections may neutrally repeat or rephrase whatever the patient has said with respect to change, causing a brief reexamination. BSo in your opinion, psychiatric treatment is not the way to go.[ Once the therapeutic alliance is solid, more interpretive reflections may be used to clarify the patient’s feelings about his or her experience. BIt seems like your parents’ insistence that you talk to a psychiatrist makes you angry because it makes you feel that they don’t care about you.[ Summary statements are longer reflections at points of transition. They help to establish the meaning of the patient’s experience as the primary focus of the treatment. BLet’s make sure I have this straight... When your teacher ignores the loud kids in the classroom, it prevents you from listening to the lesson. Then, when you tell the other kids to be quiet, the teacher gets mad at you! Do you think we could find an effective way that you could express your concerns without getting in trouble like that?[ Summary statements also can reinforce the significant progress a patient has made. BSo what you have said today is that you don’t like taking medication, but it has helped you to decrease your anger. And since you have been learning to negotiate without losing your temper, the teacher has
come to respect your opinions. It seems like you have really made a change![ StrategiesVPart II: Increasing Self-Efficacy to Sustain Momentum
To keep the change process moving forward, motivational interventions aim to increase self-efficacy: a patient’s sense of autonomy in deciding to make change and confidence in being able to do it successfully. Like all motivational techniques, those pertaining to self-efficacy are applied at any appropriate opportunity. However, the choice of technique depends firstly on an assessment of patient safety. For obvious reasons, no psychiatrist should foster autonomous decisions that include suicidal behavior or any safety threat to the patient or anyone else. Whereas rapport-building techniques may be appropriate for virtually any patient, self-efficacy enhancement requires that the patient has made a firm commitment to safety. BRolling with resistance,[ as previously noted, avoids confrontation and often helps to elicit pro-change arguments from the patient. This is akin to the martial arts technique of blending with an attack to deflect it, rather than opposing it directly. BNo, you’re not crazy, and you certainly don’t need to take a medication just because some psychiatrist tells you to.[ It applies equally well to all aspects of treatment. BYou sound pretty certain that the suggestions we have offered are not going to be helpful to you. Should we help you to find another place to get support for this issue?[ BReadiness rulers[ provide numerical ratings to measure how important making a change is to a patient and how confident they are of succeeding. BSo let me ask you: On a scale of 1 to 10, where 10 is completely important and 1 is not important at all, how important is making this change to you at this point?[ The number given in response, no matter how small, can be treated as evidence of motivation. Rulers also help break the process of change into manageable components. BYou said that you would rate your confidence in being able to improve this problem as a five. What would it take to get it to a six or a seven?[ Finally, asking the adolescent’s permission before giving information can foster his or her sense of autonomy and responsibility. BWould you like to hear about the types of medications that other people have found helpful to make this kind of change?[ Asking permission also can help get the patient to consider
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the downside of medication nonadherence, which is an essential part of informed consent. BI respect your decision, but I also need to be sure you are aware of the medical risks of stopping your medication so abruptly at this point. Can we discuss this for a moment?[ DISCUSSION
Among adolescent psychiatric patients, the quality of the therapeutic alliance with the psychiatrist can mediate treatment effectiveness. MI techniques can enhance three core elements of this important alliance: accurate empathy, patient self-efficacy, and positive attitudes toward the prescribed treatment. These strategies show promise in augmenting adolescents’ adherence to medication and other treatment components, arguing for empirical investigation of this effect. Furthermore, by boosting autonomy and personal insight, motivational strategies appear to help psychiatrically impaired adolescents develop more resilient identities. Finally, MI provides a practical means to convey three powerful but often elusive elements of the therapeutic alliance to psychiatrists in training.16 Disclosure: The authors report no conflicts of interest. REFERENCES 1. Gearing RE, Mian IA. An approach to maximizing treatment adherence of children and adolescents with psychotic disorders and major mood disorders. Can Child Adolesc Psychiatr Rev. 2005;14:106Y113. 2. Vermeire E, Hearnshaw H, Van Royen P, Denekens J. Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharm Ther. 2001;26:331Y342.
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3. Ellison JM. Enhancing adherence in the pharmacotherapy treatment relationship. In: Tasman A, Riba MB, Silk KR, eds. The DoctorYPatient Relationship in Pharmacotherapy: Improving Treatment Effectiveness. New York: Guilford; 2000:71Y94. 4. Day JC, Bentall NP, Roberts C et al. Attitudes toward antipsychotic medication: the impact of clinical variables and relationships with health professionals. Arch Gen Psychiatry. 2005;62:717Y724. 5. Sajatovic M, Bauer MS, Kilbourne AM et al. Self-reported medication treatment adherence among veterans with bipolar disorder. Psychiatric Serv. 2006;57:56Y62. 6. Joshi SV. Teamwork: the therapeutic alliance in pediatric pharmacotherapy. Child Adolesc Psychiatr Clin N Am. 2006;15:239Y262. 7. Pruett KD, Martin A. Thinking about prescribing: the psychology of psychopharmacology. In: Martin A, Scahill L, Charney DS, eds. Pediatric Psychopharmacology: Principles and Practice. New York: Oxford University Press; 2002:417Y425. 8. Pillay SS, Ghaemi SN. The psychology of polypharmacy. In: Ghaemi SN, ed. Polypharmacy in Psychiatry. New York: Marcel Dekker; 2002: 299Y310. 9. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2nd ed. New York: Guilford; 2002. 10. Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol. 1983;51:390Y395. 11. Sampl S, Kadden R. Motivational Enhancement Therapy and Cognitive Behavioral Therapy for Adolescent Cannabis Users: 5 Sessions, Cannabis Youth Treatment (CYT) Series, Volume 1. Rockville: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration; 2001. 12. Erickson SJ, Gerstle M, Feldstein SW. Brief interventions and motivational interviewing with children, adolescents and their parents in pediatric health care settings. Arch Pediatr Adolesc Med. 2005;159: 1173Y1180. 13. Gold M, Kokotailo PK. Motivational interview strategies to facilitate adolescent behavior change. Adolesc Health Update. 2007;20:1Y8. 14. Channon SJ, Huws-Thomas MV, Rollnick S et al. A multicenter randomized controlled trial of motivational interviewing in teenagers with diabetes. Diabetes Care. 2007;30:1390Y1395. 15. Sachs GS, Thase ME, Otto MW. Rationale, design, and methods of the systemic treatment enhancement program for bipolar disorder (STEP-BD). Biol Psychiatry. 2003;53:1028Y1042. 16. Weiden PJ, Rao N. Teaching medication compliance to psychiatric residents: placing an orphan topic into a training curriculum. Acad Psychiatry. 2005;29:203Y210.