CHAPTER 8
Second Step of the Choice Triad: Can a Medication Help Me?
“People are the undisputed experts on themselves. No one has been with them longer or knows them better than they do.”1
William R. Miller
From MOTIVATIONAL INTERVIEWING: HELPING PEOPLE TO CHANGE
THE CHALLENGE
Having developed an effective toolbox for navigating Step 1 of the Choice Triad, we are now ready to move on to Step 2. Before proceeding, it may be useful to review the Choice Triad itself. If you will recall, the motivational model provided by the Choice Triad suggests that, for a patient to show a genuine interest in taking a medication as well as following through with its effective use, the patient must embrace the following three beliefs:
- The patient must feel that there is something wrong from which he or she personally wants relief.
- He or she must believe that the medication has the potential to bring relief from the perceived problem (or perhaps prevent a serious future problem as with a vaccine).
- The patient must believe that the pros of taking the medication outweigh the cons.
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If any one of these three beliefs is absent, or deteriorates, it is unlikely that the medication will be continued, for it would be illogical to do so. With regard to Step 2, this belief will either be accepted or rejected by the patient by asking a no-nonsense question of themselves: “Can this medi- cation help me?” Despite its simple structure, it is a deceptively complex question. The answer will depend on a multitude of factors, some of which are knowledge based – the patient understands the theory behind the use of the medication and agrees with it – and others of an interpersonal nature
– the patient likes, respects, and trusts the clinician.
In point of fact, it is even more nuanced, for it has more than one step. It is not just that the patient must answer the question “Can this medication help me?” In addition, the patient must answer yet another question, for even if the answer is “yes” to the above question, patients will also need to ask themselves, “Is this medication the best way for me to get help?” Either the patient or the clinician (or both) may feel that an intervention such as diet, exercise, or an approach from complementary and alternative medicine (CAM) may be a better first choice.
If such is the case, and it is safe to do so, we can proceed to help the patient to effectively utilize whatever alternative approach he or she has chosen with the hope that it will indeed be successful. The less medications needed by a patient for effective healing, the better. In this regard, it is also of note that the Choice Triad (as well as many of the specific interviewing techniques of the MIM) is directly transferable to enhancing motivation and follow-through with nonmedication approaches such as diet and exercise or with CAM approaches.
Once a patient has decided that a medication is his or her preferred choice – either having chosen it immediately as the preferred choice of action when first suggested by the clinician or having had little success with an alternative approach, the patient subsequently has arrived at his or her own decision that a medication could be beneficial – the clinician will then be ready to focus on the critical process of enhancing the patient’s belief in Step 2. It is the intensity of this belief that will prove to be one of the most potent drivers of the patient’s motivation to stick with the pre- scribed medication despite the many difficulties that can arise from its use, not the least of which can be significant side effects or even more serious adverse reactions as well as financial burdens. In short, Step 2 is all about enhancing motivation.
From the clinician’s perspective, the task of Step 2 becomes one of actively helping the patient to solidify his or her own personal motivational goals while tying the promise of achieving these goals (relief of symptoms, resolution or curing of his or her disease, prevention of a potential future disease, etc.) directly to the use of the medication being prescribed. The more concretely the patient understands why he or she is taking the medication and the more deeply convinced that he or she becomes that the medication holds the most likely way to get the desired symptomatic relief or cure, the more likely that effective medication follow-through will occur. In keeping with the spirit of the MIM, for the patient to have a robust motivation to initially use and to subsequently continue to use the medication, these beliefs must be ar- rived at by the patient on his or her own terms.
THE DELICATE ART OF ENHANCING MOTIVATION
Common Sense Bridges
With some of our patients, the securing and enhancing of Step 2 of the Choice Triad is a relatively easy matter. From our joint exploration of Step 1, we will have discovered one or more powerful motivators (appearing as specific symptoms or disease states) that the patient has highlighted as problematic and with which the patient wants help. All we have to do is to make a bridge from Step 1 to Step 2 by indicating that we have a medication or medica- tions that can help the patient to obtain relief from whatever symptoms or diseases he or she has identified as problematic. As one would expect, one of the primary factors that motivates a patient toward the use of a medication is the belief that the medication may remove a disturbing symptom. The specific symptom or symptoms will naturally vary from disease to disease.
On the simplest level, a patient with strep throat will seek relief from the distressing sore throat that is so common to strep. A patient with benign prostatic hypertrophy may want relief from urinary hesitancy or frequency. On more serious levels, a patient with congestive heart failure (CHF) may seek relief from a disabling dyspnea on exertion (DOE) or paroxysms of nocturnal coughing. From Chapter 7, we have seen that questions such as the Target Symptoms Question and the Magic Pill Question can further secure motivation by collaboratively uncovering the patient’s most desired areas for symptom relief.
For other patients, or as a second motivator for the patients already focusing on symptom relief, the Diagnostic Passport, as uncovered in Step 1, may secure yet another motivational pool. In this sense, the hope of getting rid of an identified disease, by name, can be an equally potent motivator as seeking symptom relief, or in some instances an even more potent motivator.
This situation is particularly true if a patient has a serious, or life-threatening, disease. In such instances, simple phrases emphasizing the effectiveness of the proposed medication in addressing the specific disease at hand can be particularly useful; for example, “Mrs. Anderson, this set of medications is specifically designed to hit exactly this type of cancer” or “We’re going to do everything we can to slow down your rheumatoid arthritis, Mrs. Anderson, and I have several medications that I’ve found to be particularly good at doing so.”
Although somewhat obvious in nature, it is surprising how easy it is, in a hectic clinic or hospital setting, to miss the opportunity for effectively using such phrases. In addition, saying the words is not enough. It is how we say them that determines their ultimate power. To maximize their power, the clinician must gracefully embed them into the ongoing conversation, do so in an unhurried fashion, and make sure that eye contact is excellent. Moreover, the conversational moment chosen for making the empowering statement must be both well timed and memorable.
Needless to say, during such conversations, the clinician’s laptop or clipboard should be out of the way, either out of reach on a desk, a shelf, or on the floor. It is also often useful to repeat the connection between the use of the medication and its impact on the disease later in the conversa- tion to further secure its impact. In short, the clinician wants to make the statement stick. Besides increasing medication interest, such statements also can generate hope and mobilize those placebo effects that seem to impact on pathophysiology.
Thus far, we have been talking about enhancing motivation by focus- ing on the specific symptoms and/or diseases that were uncovered dur- ing our explorations of Step 1 of the Choice Triad. But some patients are motivated to use their medications effectively by factors that are unrelated to symptom relief directly. These personalized situational motivators are unique to the patient’s worldview and interpersonal situation. They are sometimes surprisingly powerful, indeed sometimes more effective at en- hancing medication interest and follow-through than symptom relief or the targeting of the patient’s disease per se.
Put succinctly, these personalized motivators arise more from the patient’s illness than his or her disease. I am reminded of yet another quota- tion from William Osler: “The good physician will treat the disease, but the great physician will treat the illness.”2 Indeed, we have already discussed the fashion in which motivation for medication use can be mined from an exploration of the patient’s illness perspectives back in Chapter 2 with our very first prototypic interviewing tip – the Inquiry into Lost Dreams.
“Inquiry into Lost Dreams” Revisited
If you will recall, the Inquiry into Lost Dreams was the technique shared by a pediatrician during one of my MIM workshops. He described how he utilized it with adolescents presenting with asthma. I want to revisit it here for two reasons. First, although introduced earlier, as a teaser of sorts, demonstrating the effectiveness of a specific interviewing technique drawn from a specific interviewing principle, the Inquiry into Lost Dreams is, in reality, a tool from the toolbox utilized for navigating Step 2 of the Choice Triad. And it is here that we can better illustrate its effectiveness contextu- ally and via clinical dialogue. Second, it is one of my favorite techniques. I have found it to be both simple to use and remarkably effective.
As noted in Chapter 2, the Inquiry into Lost Dreams evolved from the following interviewing principle: The most powerful motivators patients may have for using a medication may be directly related to regaining a lost life activity as opposed to mere symptom relief. Let’s repeat some of the material from Chapter 2 to refresh our memories.
In the workshop, our pediatrician commented that one of the most powerful motivators for some of his students was the obvious one: They wanted relief from their acute asthmatic attacks. But he found this to be true only if the student was experiencing severe and frightening asthmatic attacks, which many of his patients were not (see pages XX–XX). He discov- ered that with students whose attacks were disruptive but not necessarily frightening in nature, there often existed a more powerful motivator for using medications. Curiously, it was not directly related to relief from the asthmatic symptoms themselves. Moreover, it was a motivating factor that he found he could repeatedly tap whenever his adolescents were having tough side effects even to the extent of wanting to discontinue their meds. What was the secret to generating such tenacious medication interest?
What was the personalized motivator so common with kids suffering from asthma? He went on to describe that, more often than not, his patients were not seeking relief from something that the asthma had given them
– shortness of breath. They wanted back something that the asthma had taken from them – to be normal again. They wanted to play a sport again that they loved. They wanted to be able to function again just like the other kids. They wanted to be free of the stigma of “being an asthmatic.” It is no different with our adult patients. In many instances, patients with diseases from rheumatoid arthritis to chronic obstructive pulmonary disease (COPD) and CHF want back their dreams, their livelihoods, their peace of mind, their self-esteem, and the confidence to pursue goals without becoming beset with self-doubts. The desire to recover these lost dreams can often provide powerful motivators that may help patients to tolerate surprisingly unpleasant side effects.
Let’s review the wording of the technique:
We now have an opportunity to bring the Inquiry into Lost Dreams to life with some clinical dialogue. Let’s imagine a 62-year-old grandmother suffering from CHF and osteoarthritis (In her youth, she was a runner who ran just a little too far too often.) She is also battling about 40 pounds of uninvited weight, although she has lost about 10 pounds in the past year
– not bad. In short, she would be a fairly typical patient in any primary care clinic or private practice.
In any case, our patient, whom we shall call Mrs. Moss, has been around the block with doctors, nurse clinicians, and physician assistants for many years. We shall picture that she is meeting this physician for the very first time. We are going to pick up this interview early in their initial appointment, long before we see the clinician using the Inquiry into Lost Dreams, for this early snippet of dialogue demonstrates an important aspect of the MIM: The MIM techniques are not used in a vacuum.
As discussed above, they are woven into the conversation in a naturalistic fashion that is interdependent with the interviewer’s ongoing engagement with the patient. Their effectiveness is enhanced by the clinician’s abilities to quickly “get a read” on his or her patient’s personality style and, from this knowledge, more effectively choose and apply the MIM techniques. In this instance, the opening vignette shows us something important about Mrs. Moss that allows the clinician to more effectively employ the Inquiry into Lost Dreams later in the appointment: Specifically, despite her anxiety, she has a sense of humor:
Clin.: I’m glad to see you could make it today. I’ve been looking forward to meeting you. Your previous doctor, Dr. Jamison, sent a very nice referral letter and explained some of your problems with your heart. Hopefully I can help.
Pt.: Well, the first thing you need to do, Doc, is do something about those steps of yours.
Clin.: I’m not sure I follow you Mrs. Moss.
Pt.: Your steps up from the lower parking lot. You know, the ones that look like the steps from the movie the Exorcist (patient gives a wry smile).
Clin.: (physician finally gets where this is going and smiles) Oh, those steps.
Pt.: Yea, those steps . . . a little rough for someone with a bad heart and bum knees to climb up.
Clin.: Oh yea (pause), we probably should have told you about the upper parking lot.
Pt.: Really? There’s an upper parking lot? (patient gives a foxlike smile)
Clin.: Well, the good news is that I see that you’re not out of breath now, so that says something good about your heart function, because those are pretty nasty steps.
Pt.: I hate to burst your bubble, Doc. But the reason I’m not out of breath now is that I had to wait 45 minutes in your waiting room (accented with a pointed, yet still friendly, “umph”).
Clin.: Hmmm. (chuckling) You’re a bit feisty for someone with a bad heart.
I see I’m going to have to stay on my toes here.
Pt.: Oh, you’re going to need to do better than that. You’re gonna need an extra set of toes, Doc.
Well, I think it is safe to say that our Mrs. Moss is a bit of a pip, in a delightful fashion of course. But the good news is that there is a playfulness here that betrays both a sharp intellect, a pretty good sense of self-esteem, and the opening for the clinician to be able to also use humor as an engage- ment tool that can subsequently be utilized to provide some personalized nuances to some of the MIM techniques, such as the Inquiry into Lost Dreams. Let’s pick up our dialogue with Mrs. Moss, much deeper into her initial appointment, after the clinician’s initial history and physical examination (H&P) has been completed. Let us assume that the provider, while exploring her Diagnostic Passport, has uncovered that Mrs. Moss has a pretty good knowledge about both her CHF and her osteoarthritis.
On the other hand, while exploring her Medication Passport, the clinician has adeptly uncovered that she has considerable hesitancies about being on medications, which she has seldom taken in the fashion that her previous physician Dr. Jamison had prescribed. But she also has hesitancies about being on a diet and exercising too! In short, she is where many of our patients find themselves, between the proverbial rock and the hard place. She is obviously motivated to get symptom relief, but it’s not enough to keep her on her meds.
Can our provider help Mrs. Moss to mobilize a personalized, situational motivator in the same fashion as our pediatrician so adeptly does with his adolescents with asthma? The Inquiry into Lost Dreams is designed explicitly to do just that:
Pt.: You know it’s frustrating at times, the shortness of breath, I mean.
Clin.: Oh, I’m sure it is. I would imagine it is very frustrating. It sounds like it’s even tough for you to get upstairs sometimes.
Pt.: Oh, I don’t even go up to the third floor anymore . . . not worth the trouble, if you know what I mean. I’ve not only got the functional heart of a mouse, I’ve got the knees of a dead horse.
Clin.: Not good.
Pt.: No, not good.
Clin.: You know, Mrs. Moss, after listening to your history, I’m starting to get some ideas about how I might be able to help, but I’d like to get an even better idea of how much your heart condition limits what you can do. Think carefully about this one. Is there anything that you really want to do, that you just can’t do, you know something that it really pains you that you can’t do because of your heart condition? (Inquiry into Lost Dreams)
Pt.: (pauses, then sits up with a little more emotional charge) Why, yes there is. You know what really hurts me . . . I have the most lovely granddaughter, with the lovely name of Kamala, out in California, and when she was 3 years old I promised her that Gran “will someday take you to Disneyland.” And you know what, I don’t think it’s ever going to happen. And what really bugs me is that she’s ten now, and pretty soon, she’s not going to want to go to Disneyland with Gran anyway.
Clin.: Well, that’s sad. I can see why it hurts you so much. (pause) You know, what is it exactly that frightens you or makes you hesitant to go?
Pt.: Part of it is the airports and the plane. The last time I flew out there was over 2 years ago, I made it alright, but it was a real pain. It’s just too much walking, and I hate being wheeled around in a stupid wheelchair, it’s like I’m an old fogey or something. (pause) And I
have to bring the oxygen sometimes and that’s a pain in the butt. And I’m afraid that even when I get there, which I think I could manage, I wouldn’t be any fun at Disneyland I’m afraid to say (almost tears up).
Clin.: Well, you know what?
Pt.: What?
Clin.: I really think I might have a medication that might help. It might actually help enough to get you out to Disneyland. I can’t make a promise that it will, but I certainly can promise that I can try. And even if it can’t get you out to Disneyland, I do think it might help your breathing considerably. If it’s okay with you Mrs. Moss, I would like to see if you would be comfortable working with me to at
least see if that is possible. What do you think? (Inquiry into Lost Dreams completed)
Pt.: Well . . . (sitting up, with a brighter affect, and a bit of a twinkle in her eye).
Clin.: Now don’t get overexcited, (said smiling) I can’t promise you a date with Mickey Mouse or anything!
Pt.: Doc. I decided a long time ago that I’m done with mice and men, ain’t worth the trouble. But I’d sure like to get a picture of Kamala getting a big hug from that mouse. Now that’s something I’d like to see.
Clin.:That’s a wonderful image. Let’s keep it in mind. It’s a great rea- son to try the medication that I have in mind, and to see if it can help. Let me tell you a little bit about it, both the pros and cons, and you can see what you think about giving it a try. It’s called . . .
This is an impressive demonstration of the Inquiry into Lost Dreams being seamlessly woven into an initial appointment following the H&P. Note also that, from the initial dialogue, the prescriber recognized that one could capitalize on Mrs. Moss’s sense of humor to personalize the Inquiry into Lost Dreams. The clinician did so with the quip about Mickey Mouse. The resulting image that Mrs. Moss spontaneously generated – of Mickey Mouse hugging Kamala – is a potentially powerful motivator for her interest in trying a medication. It is also a motivating image she can return to over and over if her motivation might be challenged by side effects.
At such moments, it is also an image that the clinician can intentionally pull on, perhaps in a situation when the clinician might believe that the side effects could be reduced, if only the patient would not unilaterally discontinue the med between appointments, as with, “I know you’re having some tough side effects – and they are tough – but fortunately, I have some ideas on how we might be able to make them much bet- ter, and I don’t think we have seen the full power of this medication to help with your breathing just yet. Remember, we are still trying to get that picture of Kamala with Mickey, so if you can hang in there just a little bit longer, Mrs. Moss, it will give me a chance to see if I can get rid of some of these side effects for you. If we can’t do that, well, then we will need to come up with something different. Here is what I sug- gest we try . . .”
A Variation on a Theme
In the above example, a transformative moment is occurring before our very eyes thanks to the skilled interviewing of the clinician. The Inquiry into Lost Dreams represents an easy-to-use, single interviewing technique for tapping highly personalized and, hence, meaningful motivators for patients. I have found it to be very fruitful for many patients, indeed most patients, but some patients may have difficulty identifying concrete losses or positive changes they want to make in their life.
It’s my belief that such patients may cognitively handle stresses dif- ferently than others, perhaps with a little less concrete organization and directed problem solving than those patients who respond quickly and easily to the Inquiry into Lost Dreams. These patients have curiously not kept tabs on their specific losses, per se, so much as feeling a more over- whelming sense that all is lost or “everything is different.” For such patients, I find that it is sometimes easier to approach the topic slightly differently by generically asking them to reflect on how their life might be different if a specific symptom or disease was gone.
This approach, which gently posits a “What if . . .?” kind of question, can often help them to discover powerful motivators that lie deep within their souls and that they had never fully consciously grasped as possibilities for achievement. I think you will find that if a patient does not offer much response to the Inquiry into Lost Dreams, you can pull the following closely allied variation of the Inquiry into Lost Dreams out of your toolbox. It is known as the Alternative History Question, and, depending on the disease in question, it sounds something along the following lines:
Depending on their specific disease state, the patients’ answers can greatly vary, but not infrequently, and they will carry a deeply personalized and emotional charge. Patients often respond to the Alternative History Question with answers like “I’d be able to play tennis again and be able to mow my own lawn instead of depending on others” (osteoarthritis); “I’d date again, I feel so embarrassed going to the bathroom constantly, and I wouldn’t be worried about getting an erection, I have had so many em- barrassing situations. I feel so old” (prostate enlargement); “I could work again. I wouldn’t have to feel like I’m a misfit who everyone thinks is fak- ing it” (migraines); “I’d have my own apartment,” “My family would want me around, and they would want me home for Christmas again,” “Maybe I could go to college, I’d really like to do that” (schizophrenia).
With regard to the latter – patients coping with schizophrenia – the answers of my own patients are sometimes so laden with pain, for the ill- ness has decimated their sense of self-respect, that tears may follow the use of the Alternative History Question. And, indeed, if during my subsequent discussion with my patient, he or she arrives at an understanding that a medication might represent a viable pathway to regaining one of these lost dreams, we will have collaboratively found a powerful motivator for sparking medication interest.
As we did with the Inquiry into Lost Dreams above, I’d like to contex- tually illustrate the Alternative History Question as it is being gracefully employed in a clinical setting. To do so, I’m going to illustrate its use not with a medication per se, but with an example from surgery. I believe we will find this useful for two reasons: (1) Surgery is often one of the most difficult therapeutic interventions to convince patients to undertake, for, frankly, it is scary. If we can show the effectiveness of the employment of the Alternative History Question with something as imposing as surgery, we will have created a fairly convincing argument for its use with medications. (2) I had mentioned earlier in this chapter that I thought you would find many of the techniques of the MIM directly transferable to increasing interest and motivation with a variety of nonmedication interventions, such as diet, exercise, physical rehab, meditation, diagnostic procedures, and surgery. Such recommendations for interventions are part and parcel of everyday practice in primary care settings such as family practice and internal medicine as well as in specialties ranging from cardiology, pulmonology, and endocrinology to physical medicine, psychiatry, and surgery. This example will highlight this potential.
Let us imagine an orthopedic surgeon talking with a patient in his late 60s, who has been suffering from severe osteoarthritis for over 15 years. Mr. Blount, who prefers to be called by his first name, Desmond, has been highly opposed to the idea of bilateral knee replacements. A retired lawyer, he has tried a variety of alternative treatments, such as acupuncture, which years ago had provided moderate relief but is no longer effective. He has also been tried on a variety of nonsteroidal anti-inflammatory drugs but there are concerns about creating a potential bleeding diathesis, consider- ing his advancing age. He has chosen to avoid the use of opioids for fear of addiction. Steroid injections are becoming problematic, appearing to be causing further joint damage as an adverse reaction.
The picture is further complicated by a unique factor that hangs like a shadow over Mr. Blount’s contemplation of surgery. He had a nephew who developed a severe infection following a knee replacement. Within a week, his nephew threw a pulmonary embolism and died.
Mr. Blount clearly has ample reason to be hesitant about surgery. We are picking up the conversation late in a scheduled follow-up appointment in which his potential surgeon and he had once again been discussing the pros and cons of surgery, of which Mr. Blount remains leery:
Pt.: Truth be told, I’m in pretty bad pain all the time, but you know, I’d rather be in pain than dead. (pauses, looks up at the surgeon with a bit of a defeated look) I just don’t know what to do.
Clin.: Desmond, you have every right to be hesitant about surgery. It’s always sort of scary. I’m hesitant about surgery for myself, and I wouldn’t have it done unless I felt it to be necessary. (Notice how this surgeon is deftly applying the spirit and principles of the MIM by creating a nonoppositional alliance with Mr. Blount by moving with him on the Agreement Continuum. If this has been his interview- ing practice over his previous appointments with Mr. Blount, he has probably already secured some of the key interpersonal factors, such as respect and trust, that, as we mentioned earlier in the chapter, are prerequisites for a patient to answer “yes” to the question “Can this medication – in this case surgery – help me?”) But I wouldn’t suggest the replacements unless I really felt that they would go well for you. And we’d do them one at a time, so you’d get a chance after the first one to see if the pros outweighed the cons or not.
Pt.: Yea, yea, I know. (pauses) Don’t get me wrong, I really trust you. (bingo) That’s not it. I just don’t know. (pauses) The pain is really bad, I, I . . . I just don’t know.
Clin.: Well, it’s a tough decision, and you don’t have to make up your mind right now. (still no pressure from the surgeon) I think I’ve got a pretty good idea what your worries are, and they are legitimate, especially after what happened with your nephew. In helping you to weigh things here, I think it would help me if I had a better idea of what some of the benefits might be. (Notice that the surgeon is not going to tell Mr. Blount – or “lecture him” about – the benefits of surgery; he is going to let Mr. Blount discover the benefits for himself.) You know, what if we did the knee replacements, and you had essentially no pain when you walked, and I don’t think you will, what would you be able to do differently in your life that you can’t do now? (Al- ternative History Question)
Pt.: Hmmmm (pauses, then smiles) I’d get a dog. I adore dogs. I had two Springer Spaniels, Maddie and Wendy. I loved them to death. We’d go out for long walks out in a field behind my house, sometimes with a light snow falling. Really magical. (pauses) But after they both passed I realized I just couldn’t keep up with a new dog. As my knees got worse, I couldn’t even take them out for walks. It wouldn’t be fair to a dog if I can’t take them out for walks for god’s sake (sighs). I sure miss having a dog, especially a Springer.
Clin.: They’re sort of wild things aren’t they (smiles), Springers, I mean. I’m not sure anyone can keep up with two Springers. They’re not called Springers for nothing!
Pt.: Oh, they’re nutballs alright! (chuckles) I love them. Really affection- ate too!
Clin.: Well that sounds like a good change. I bet it would be great fun to walk with a pair of Springers again, out in a snowy field. (pauses) What else might you be able to do? (Alternative History Question repeated).
Pt.: Hmmm. I never really thought about this, but I’d start to travel again. My wife and I used to travel a lot, Italy, Spain, even China (looks ani- mated), but the airports were just too much. They make them so you have to walk so damn far. It was just too much. And I hate, I mean I hate, driving in a damn scooter or being wheeled about in some cart for old people. But if my knees were okay, wow, if they were really okay, I’d be on a plane in no time.
Clin.: Sounds good to me, just get me a ticket if you’re going back to Italy (both laugh). What else would be different? (Third employment of the Alternative History Question)
Pt.: Oh, I don’t know. I, I, well, there’s a brook down deep in the woods behind Laurie’s and my house. We used to go down to that brook al- most every week, except in the winter, and I spent a lot of time down there alone. (pauses) It’s sort of place where I’d find my soul. Yea, I miss that, I miss that a lot. (pauses) Dr. Miller, are you really telling me that you think I could do these things, really? Without much pain?
Clin.: (smiles) Really. (pauses) Perhaps, no guarantee, but perhaps with no pain, but certainly with a lot less pain. Just like old times. You know, Desmond, I can never guarantee anything with surgery, but from my experience, and I’ve had a lot of it, I think your chances for a very good outcome are excellent.
Pt.: (sighs and sits up with a bit more spunk). I don’t know, maybe I might want to try one knee. Which would you do first?
Truly skillful interviewing, and it looks like it is paying off. One would be hard-pressed to see a better example of shared decision making. In it, we have seen our surgeon intentionally use a single interviewing technique
– the Alternative History Question – three times. Notice that it was the patient that produced the motivators, not the surgeon.
In a similar fashion, whether talking about surgery or using medica- tions, I truly believe that many patients hold the keys for motivation locked inside them. They are often deeply personal motivators of which we might have no knowledge. The goal of the clinician becomes one not of telling patients why they should take a medication but learning from patients why it would be wise to do so. Skillfully, and intentionally using interviewing techniques such as the Inquiry into Lost Dreams and the Alternative History Question clinicians can optimize the chance that patients will discover for themselves why they would want to take a medication. I am reminded of the wise words of Richard Miller from our opening epigram of this chapter: “People are the undisputed experts on themselves. No one has been with them longer or knows them better than they do.”
Our surgeon could have spoken in generalities to Mr. Blount, telling him that he would be much more mobile if he underwent knee replace- ments and, “You could do a lot of things that you can’t do now.” Such generalities pale in intensity compared with Mr. Blount’s self-generated image of himself walking through a snowy field with two Springer Spaniels bounding about. The former is a light tug toward surgical interest, and the latter is an almost irresistible pull.
The above illustration demonstrated the use of the Alternative History Question with regard to a surgical procedure, but one can imagine its al- most daily utility in a busy primary care or specialty clinic when addressing smoking cessation with a patient suffering from COPD, while recommend- ing diet with a patient coping with obesity, or an exercise regimen for a man with a metabolic syndrome rapidly heading for full-blown diabetes. Both the Inquiry into Lost Dreams and its close sister, the Alternate His- tory Question, are not magic, but they sometimes seem to be so. Simple. Powerful. Easily taught. Easily learned. Easily utilized.
What if the Disorder Has No Symptoms?
The power of the twin techniques of the Inquiry into Lost Dreams and the Alternative History Question lies in the fact that the symptoms caused by our patient’s diseases are causing considerable pain and loss of functioning. But in everyday primary care and specialty care clinics, such is frequently not the case. Many of the diseases that clinicians encounter do not dem- onstrate many, if any, symptoms in the early stages of the disease (e.g., hypertension, hyperlipidemia, the metabolic syndrome/early diabetes).
One trick of the trade with such symptomless diseases stems directly from our understanding of the Inquiry into Lost Dreams. Perhaps we can adapt it for use with hidden diseases by communicating that a dream may be lost in the future if medications are not effectively utilized:
If we reflect back on Mrs. Moss from earlier in the chapter (the grandmother who wanted to take her granddaughter to Disneyland), yet another avenue comes to mind for uncovering motivators for patients with symptomless diseases. Patients can have powerful reasons for taking medications that are based primarily on the idea of helping others. In many instances, these interpersonal motivators can be a great deal more compelling than simply taking a grandchild to Disneyland (important in its own right). Sometimes a patient feels that if he or she does not take a medication, catastrophic events may befall loved ones. It is this avenue that provides some keys for helping patients to find previously untapped motivators for using medications effectively.
In this regard, a primary care physician from Los Angeles shared the following technique at one of my MIM workshops. I have found it to be very effective. It introduces a theme that is of immense importance: un- derstanding the critical need – when helping patients to find motivators unique to themselves – for interviewers to be facile at effectively navigating cross-cultural issues and divides.
The clinician was White, but much of his work was with the Latina/o population. He found that Latino males often didn’t want to take medications for their symptomless diseases, such as hypertension, for “taking care of oneself” is viewed as being self-centered. On the other hand, the Latina/o culture places a profound emphasis on family ties and responsibilities, which displays itself as an intense belief in taking care of one’s spouse and children (as well as extended family) no matter what the cost. Family needs first. Individual needs second.
Spending precious money on medications, when “there is nothing wrong with me – symptomless disease such as hypertension – when I need that money for clothes and food for my kids” simply flies in the face of the patient’s cultural ethics. Indeed, all of the risks and dangers of un- documented immigration are often undertaken because of profound and pressing needs to help one’s family survive.
The family practitioner commented that convincing young Latino fathers to take medications for asymptomatic diseases was often an insurmount- able barrier to medication interest and follow-through. He related that one day he inadvertently stumbled on the solution when he was eliciting the routine family history during an initial H&P. We will call the patient Miguel. When he asked Miguel whether anyone in his family had had a heart attack or stroke, the patient commented, “Yeah, my father. He died of a heart at- tack (pauses), . . . it was the worst day of my life. He was the greatest man I’ve ever known.” When asked how old he was when his father died, he commented, “Way too young, I was 12.” The patient welled up with tears.
At this point, the proverbial “light bulb” went off in the clinician’s mind. The light bulb in question can be summarized by the following interview- ing principle: Actively explore with each patient the potential interpersonal motivators that might ensue, regarding loved ones, if the disease should worsen or death result. During the closing phase of the interview when the clinician was recommending the use of an antihypertensive, he put this principle into practice with the following interviewing technique:
TIP 24 Tapping Family Motivators
“Miguel, i know you don’t feel much like taking these medications for your high blood pressure, and i under- stand that. There might be another reason, in addition to taking care of yourself, why it may be very important for you to try to take them. i think they can help you to take care of your family. You see, i don’t know if your father had high blood pressure like you have, but it commonly runs in families from generation to generation. i think he very possibly did. And high blood pressure is one of the num- ber one causes of heart attacks. i think there is a very good chance it is what caused your father to have his. This medi- cation is designed to help prevent heart attacks, something that you know from your own experience would be horri- ble for your wife and kids. i can’t guarantee you that it will prevent you from having a heart attack, but i think there is a good chance it will. we need to keep you healthy, not just for you, but for your two children. our goal is to try to lower your blood pressure so that we can protect your heart. And if we do this right, we might be able to pre- vent your two children from going through what you went through when you were 12. (pauses) . . . You know, this warning might just be the last great gift your father gave to you. what do you think?”
To me, this interviewing exchange was brilliant. The family practitioner focused on his patient’s cultural matrix both in a general sense (Hispanic pride in familial responsibility) and in a personal sense (Miguel’s loss of his father at an early age).
The physician commented that he had found this tip to be useful from that day forward, with rather startling increases in medication interest in this specific population. He uses it with asymptomatic diseases, such as hypertension, hypercholesterolemia, and diabetes.
It is also useful for patients whose symptomatic diseases have been in remission for long periods of time to help them to keep in mind why they are taking the medication, for such diseases have paradoxically become symptomless because of the impact of the medications. From a personal standpoint, I have found that Tapping Family Motivators can be very useful with many psychiatric conditions, for some of which – in a primary care setting – you will be providing direct care (mild to moderate depressions) or indirect supportive care (bipolar disorder and schizophrenia). For instance, when some patients suffering from bipolar disorder move into a strong remission, they still have regrets about what the bipolar disorder “put my family through.” Tapping Family Motivators can be a particularly powerful technique for keeping this motivational awareness vibrant for such patients. This technique can also be expanded beyond family members. For some patients, such as teachers, ministers, physicians, nurses, and social workers, it is their commitment to their communities and to helping others that stands as a powerful motivator for them to stay healthy and capable of helping. As one would expect, this tip is of great use not only among the Latina/o population, but across all cultures when we find individuals
possessing a high sense of responsibility to family or mission.
Ed Hamaty, a pulmonologist and hospitalist, added that such family or community motivators, as described above, can be enhanced significantly by helping patients to create individualized affirmations such as “This one is for my grandchild.” Simply repeating this affirmation every time the patient reaches for his or her medication bottle can go a long way toward inspiring motivation. To optimize its power to enhance medication interest, it is important to reenforce it over time.
Another primary care clinician had an excellent interviewing technique to accomplish that exact task. A nurse from Kansas, Janet Brack, suggested a clever extension of the above interviewing technique. She asks patients whether they might have a photograph of their children with them. If they do, she asks to see it. Naturally, no matter what the appearance of the child or children might be, she enthusiastically comments how cute the kids are. She then employs the following technique:
If safety is an issue, as it would be with digoxin and two kids in the house, the photograph can be taped or placed inside a medicine cabinet that is locked or out of reach of children.
Speaking of kids, I am reminded of a very clever tip for prompting an adult patient to take medications in an ongoing fashion, once again based on the patient’s concern for his or her children. This tip was provided by one of my MIM workshop participants. I never would have thought of it in a million years, yet it is not only clever, it is effective.
Having done a social history, during the initial H&P, the provider can make a concerted effort to find out whether the patient has a child or adolescent with a chronic disease that requires medications. If the child dislikes taking his or her medication or the adolescent has trouble reliably taking his or her medication, the provider can use the following tip:
The above tip can be useful with both symptom-laden diseases and symptomless diseases – the topic of this section. But I think it is particularly useful for symptomless diseases for it reminds the patient that taking his or her medications, which might not seem so pressing a matter to the patient (for he or she is not experiencing symptoms), is important for helping his or her child who does have painful or disturbing symptoms.
With the deployment of this interviewing technique, the clinician has helped the patient – with a symptomless disease – to associate the taking of his or her medication with the relief of an actual symptom of great im- portance to the patient. Paradoxically, it happens to be a symptom plaguing his or her child.
With regard to helping patients with symptomless diseases not only to be aware of their diseases but also to actively consider that the control of their disease is directly dependent on effective medication follow-through, it is useful to return to the topic of patient education. The following tip can help your patients to better understand the importance of their “numbers” (whether the numbers are blood pressure readings, blood sugar values, or their A1C value), for such numbers may be the only “target signs” of their asymptomatic diseases. It can be very hard to be motivated by abstract numbers to persistently take a medication, especially if there are bad side effects. It is also difficult for patients to associate these numbers with the use or lack of use of their medications.
In any case, I think you will find the following strategy to be valuable in both highlighting the presence of the disease (reenforcing Step 1 of the Choice Triad) and tying the use of the medication directly into the numbers being used as gauges of success in treating the disease (addressing Step 2 of the Choice Triad). In short, the Back-Burner Strategy makes the “numbers” real.
TIP 27 Back-Burner Strategy
“My role is not to scare you, Rohan, but to help you to understand why it is so important to take care of your ath- erosclerosis, so that you have some real choice in how to keep yourself healthy. The problem with atherosclerosis
is that it is the type of problem that is a delayed problem, that sort of sneaks up on us. For myself, i always find such problems to be tough ones because it’s easy for me to put them on the ‘back burner,’ when they really need to be on the front burner.
“it’s like we’re cooking up a big Thanksgiving dinner, and we have some of the side dishes on the back burners of the stove hidden away behind the pots on the front burners. it’s so easy, when we get busy making the potatoes and tending to the turkey, to lose sight of what is cooking on those back burners, but what’s cooking is getting hotter and hotter. Suddenly, without any warning, the gravy is boiling and spilling over all over the place, and we got a real mess on our hands.
“Atherosclerosis is just like this. it may slowly, over the years, get worse and worse, so that our arteries, as i
showed you before, may get more and more clogged, and then boom, like the pots on the back burner boiling over, our arteries may shut down suddenly even if they are not entirely clogged. And just like it’s too late with the burned gravy or the scorched vegetables, we have a real mess on our hands. only this time, the mess isn’t a ruined meal; it could be something like a heart attack or a stroke.
“we need to bring the problem of treating your atherosclerosis onto the front burners, where you can take care of it, to help prevent it from ‘boiling over.’ And it’s keeping track of those numbers we talked about that can help keep it on the front burner for you, that will let us both know how ‘hot the food in your pot is getting,’ if you know what i mean. By following your blood pressure numbers, we may have a much better idea of what is going on with your arteries.”
Depending on the patient’s cultural context, I have found it to be useful to flexibly change the metaphor used in the Back-Burner Strategy. For instance, if the patient is a trucker or mechanic, one can talk about the need to routinely check the oil in the engine, and that it’s easy to forget to do so, but it’s very important to do so for the engine can be destroyed if one does not “keep up with the numbers.” Techies can be reminded of the importance of keeping up with recommended virus updates or their computers can become hostages to ransom-ware. What- ever metaphor fits the patient best becomes the metaphor of choice for a skilled clinician.
In addition to interviewing techniques such as the Back-Burner Strat- egy, well-organized educational approaches such as the use of illustrations, models, and web-based animations can help patients understand the potential consequences of unchecked symptomless disease states. In addi- tion, the entire process can become more personalized and reality based for some patients by having the patient chart his or her own numbers or perhaps by downloading an app that does the charting for the patient and subsequently shows the patient’s progress graphically.
Generalized Techniques for Bolstering Belief and Excitement About Medications
We are not going to have the same confidence in all of our medications, and we should never feign confidence when we do not have it. But if you feel a medication has a good chance of helping, it is often useful to share that optimism with the patient. Keep in mind that all medications carry within them a potential placebo effect. This placebo effect is not something to be ignored; it is something to be enhanced. Placebo effects sometimes cure. In other instances, they may enhance the pharmacologic efficacy of medications or independently change pathophysiology by themselves, as has been seen in several antidepressant studies.3,4
If the prospective medication has demonstrated good results in well-controlled clinical trials, I go out of my way to let the patient know of this fact. I also find it useful to be specific about instances in which the medication has personally been valuable with my own patients. Such personal endorsements by me are often much more persuasive to patients than a horde of research studies. Fortunately, we can take advantage of both approaches as follows. Imagine for a minute that we are talking with a patient about one of the newer medications for psoriasis:
Another rich yet often overlooked opportunity for enhancing patient belief revolves around the process of writing out prescriptions. Our written prescriptions are not only sterile communications to pharmacists about medications, but also, for some of our patients, they are tangible symbols of hope. Curiously, from the perspective of cultural anthropology, prescrip- tions share some striking similarities to talismans, even to the point of being partially written in a secret language (Latin) that is understood only by the healers of the culture but not by those people seeking the help of those healers. I’m not suggesting that prescriptions are talismans, but I am sug- gesting that symbolically, like talismans, they may be powerful enhancers of the placebo effect in their own right.
As such, it may be useful, from a psychological perspective, “to charge them” with the power of our own belief. A patient with intractable pain, debilitating depression, or AIDS is looking for hope, even if the hope is for just a small relief in suffering. This is a hope that talented physicians sometimes enhance, not only by their choice of medications, but by how they handle the pieces of paper that procure those medications.
Obviously, a handwritten prescription lends itself admirably for use in the Talisman Effect, for it represents something the patient can tangibly hold and take home. It may also be bolstered by the presence of “magi- cal” Latin script. But as many of us are moving toward electronic scripts, the savvy clinician can still employ the Talisman Effect. Even though the formal prescription may be sent electronically, one can still write down the directions for the medication on a separate “official” piece of paper with the letterhead of the clinic or hospital certifying its importance.
One can then undertake the exact same protocol with regard to “charg- ing the talisman.” In addition, as research has shown, carefully reviewing how one should take one’s medications enhances the likelihood of effective medication follow-through. With a single technique – the employment of the Talisman Effect – the clinician can simultaneously enhance the likelihood of a placebo effect while increasing the likelihood of effective medication follow-through. Not bad for a single interviewing technique.
A very simple variation of the Talisman Effect was given to me by a physician, Grant Chernick, during one of our MIM workshops. When handing a patient his or her prescription, he looks the patient right in the eye while confidently commenting, “Well, here’s your prescription, I trust it will help!” It can be surprising how something as simple as this varia- tion of the Talisman Effect can provide a potent jolt of hope in a patient, especially if the clinician in the previous ongoing therapeutic alliance has secured the patient’s trust and respect. Patients do care what we think, especially if they like us.
As I end this section, I am reminded of one of my favorite tips. It was provided by a pediatrician, Dipankar Mukhopadhyay, and it delightfully captures the magic and unique solutions sometimes required when working with small children. If you have built up a good ongoing relationship with a child and his or her parents, the following approach can be both great fun and highly effective for improving medication interest in a small child. The tip addresses a common problem in pediatrics: toddlers fussing about taking medications. Sometimes, it is hard for small children to truly understand why they are taking medications, and once they decide they don’t want to be bothered, tantrums and tightly clamped lips are not far behind.
The tip is based on the fact that little kids sometimes get a kick out of the idea that they have to “keep tabs” on Mom or Dad rather than vice versa. This phenomenon can be put to good use in helping kids to get interested in taking their medications. After writing out the script, the clinician turns and hands the script to the young patient, saying as in the following tip:
Engaging these young patients in the “monitoring” of their parents’ behavior usually gets a chuckle from the parent and an enthusiastic nod from the child. This technique is a wonderful example of “externalizing the problematic behavior,” a technique often useful with children and adolescents. For instance, a child who has been teasing another child may be told that there are problems with teasing at school (and why it is a problem) and then may be asked to help make sure it is not happen- ing anymore in the hallways, perhaps being used as a hallway monitor. Having been “hired” as a monitor, such a child may suddenly cease all teasing behaviors. When you see it work, it is really quite remarkable. In any case, you may be able to find other uses for “externalizing prob- lematic behaviors” when attempting to increase medication interest even with adults.
Having created a practical toolbox filled with interviewing techniques for helping patients to find personalized motivators for medication use, one more step in the Choice Triad must be navigated before medication interest is solidified and medication follow-through is secured. Patients can believe that there is something wrong with which they want help (Step 1), and they can believe that a medication may be the answer for achieving specific personalized goals and symptom relief (Step 2), but unless they believe that the pros of the medication truly outweigh its cons, they would be foolish to take it. I would never take a medication that I felt would hurt me more than help me. Would you?
REFERENCES
- Miller WR. Motivational Interviewing: Helping People Change. http://goodreads.com/ author/quotes/128663.William_R_Miller. Accessed December 02, 2016.
- Jakovljevic M, Ostojic L. Person-centered medicine and good clinical practice: disease has to be cured, but the patient has to be healed. Medicina Mostariensia 2015;3(1–2):2–5.
- Leuchter AF, Cook IA, Witte EA, et al. Changes in brain function of depressed subjects during treatment with placebo. Am J Psychiatry January 2002;159:122–129.
- Mayberg HS, Silva JA, Brannan SK, et al. The functional neuroanatomy of the placebo effect. Am J Psychiatry May 2002;159:728–737.
