Motivational Interviewing; a change of attitude.
So many people with IBS complain that their doctor never listens to them. This is not just because the doctor does not have enough time or they engage with the data on the computer instead of their patient, it is more often to do with the style of the engagement. Too many doctors conduct medical interviews as an interrogation: where is the pain, is it cramping, burning, stabbing, how long have you had it, does it come and go, what brings it on, what relieves it, is it associated with anything else, and of course, what are your bowels like? This check list of questions are implanted in the subconscious of every doctor at medical school. They are designed to elicit answers that are direct and to the point. This style of interrogation allows doctors to filter their patients’ answers and focus down on the putative diagnosis, but leaves no time to explore the context of the illness.
Motivational interviewing developed from what American psychotherapist, Carl Rogers called Person Centred Therapy. It is not so much a new charismatic practice, but more a different way of being with a patient that facilitates change. It is particularly useful for helping people manage those illnesses that have no clear cut medical cause or diagnosis and no specific treatment; illnesses that are an expression of the individual and their social and cultural environment.
Motivational interviewing allows the patient to understand their own illness and gain sufficient confidence to discover for themselves the best course of management. More of an engagement than an interrogation, questions tend to more open ended. This gives patients the chance to express how they feel and their doctor to listen and reflect on what has been said, identifying any discrepancy between the way people wish to see themselves and their behavior and seeking clarification. More collaboration than instruction, the patient is enabled to identify the problem, articulate the potential benefits of change and have the freedom to act.
Motivational interviews let the patient tell the story of their illness and how they are feeling, while the doctor picks up on the cues that reveal the context and the best route to symptom relief. In this way, patients are not so much told what to do but allowed to develop the confidence to discover for themselves what might work for them.
The emphasis is on empathy, acceptance and facilitation. Interviewers neither instruct nor show patients what to do. Instead they give them insight into dysfunctional patterns of behavior, judgement to contemplate change and determination to make it.
Doctors do not have the time to listen to everybody’s story, but there is no reason why other health care workers with less workload cannot see the patient, only referring to the doctor when specific medical expertise in required. Moreover, motivational interviewing is more a matter of attitude than time. With practice, it is quite possible, by listening carefully and picking up on cues, to get to the heart of the problem in a few minutes. The same principle applies to questions that are sent in by e-mail; it is so often a matter of reading between the lines.
Over the last hundred years, people have been too conditioned to see their doctor as the Oracle; the answer to all their problems. The reality is that only their patients really know what has happened, but they may need to be helped to see it. Open questions: What was going on when the illness first started? What makes it worse? What relieves it? What do the symptoms mean or remind you of? – often reveal the vital context of the illness. .
Motivational interviewing has been successfully used to correct dysfunctional conditions such as alcohol or drug addiction, eating disorders or aggressive behavior, but doctors and counselors are now using it to help people with unexplained illness.
Long term illnesses like IBS rarely have one single dominant cause. They are more a state of being and conflicts over reactions to the things that happen and make things so much worse. Gaining some insight into this can put people in control of their own illness.
So reflect, think about the broader context of your illness, understand the situations that upset it, ask yourself why that might be – but be aware when things do not conform to the usual pattern and know when to seek advice.
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