On many a Friday, Dr. Joji Suzuki goes trawling through the medical wards of Brigham and Women’s Hospital with trainees in tow, looking for smokers.
One recent Friday, he finds Thrasher West, a patient who'd had trouble breathing but now is about to go home, where a tempting half-a-pack of cigarettes awaits her.
Dragging in the smoke, blowing it out — smoking feels good to her, West tells Suzuki. But then, she thinks, "Damn. Why’d I do that? Because it’s not good for me --" (Here, her deep cough adds emphasis.) "It’s bad for my health...Aw, I’ll give it up when I finish the pack."
Suzuki, the hospital's director of addiction psychiatry, does not lecture her about the risks of smoking. He does not suggest nicotine patches or pills or any other aids for quitting. He just mostly listens, and thoughtfully echoes what she says, and draws her out — when, for example, she mentions that she once quit for five years.
"Something happened, and you made a decision to stop," he probes.
Her sons begged her, West recalls. One said, "Mommy, please stop smoking, please stop smoking."
"Pleading with you..." Suzuki reflects.
"He had tears in his eyes. And he’s my baby, that’s my baby boy." She reassured her son that she would be around for a long time, she remembers, and he answered, "You keep smoking, no, you won't!"
Suzuki interprets: "They love their mama so much, they don’t want to lose her."
The conversation, lasting just a few minutes, may sound like a simple chat. But Suzuki is expertly following principles that have been hammered out over decades and studied in copious research. He listens — actively, empathetically — more than he talks. His comments and questions remind West of her reasons to quit, and bolster her confidence that she can do it. They tap into her values and goals — her love for her family, her desire to live.
By the end, West says she wants badly to stop smoking, and she urgently asks Suzuki to write her a prescription for nicotine patches.
She has just experienced the subtle power of a method that’s increasingly popular in medicine: It's called motivational interviewing, often referred to just by its initials, MI.
"The big shift in the practice of MI for most practitioners is that you go from telling patients why they should change or how they could change to drawing out from the patient their own ideas about why change would be beneficial to them and about how they might be able to do it," says Dr. Allan Zuckoff of The University of Pittsburgh, a national leader in the field and author of a new self-guided book, "Finding Your Way to Change: How the Power of Motivational Interviewing Can Reveal What You Want and Help You Get There.”
Motivational interviewing goes back decades in the field of addiction counseling, Zuckoff says, but in medicine, it’s been really taking off in the last few years.
Hundreds of studies have been published on using it in health care, from diabetes control to reducing the risk of heart disease. It's being tried for patients with incontinence, psoriasis, hepatitis C, Parkinson's — virtually any disease in which the patient's behavior — taking medication, choosing food — affects the outcome. And of course, it can be used for the lifestyle issues that are the biggest driver of American chronic illness: overeating, smoking and drinking and drugs, lack of exercise.
Motivational interviewing changes the dynamic, the whole style of doctor-patient communication, Suzuki says. Doctors are used to giving something to the patient, "whether it's advice or skills or recommendations, a prescription, a diagnosis, a treatment plan, a referral." But none of those, he says, will help with the key to changing behavior: a person's internal motivation.
When motivational interviewing first clicked for him, "I felt so much more helpful," Suzuki recalls. "We weren't butting heads. The analogy that people often use is that instead of wrestling, it's like dancing."
"The analogy that people often use is that instead of wrestling, it's like dancing."Dr. Joji Suzuki, on motivational interviewing
Patients with unhealthy behaviors often feel either judged or controlled, Zuckoff says. “The person talking to them is either trying to get them to do something they don’t feel ready to do, or conveying a critical or negative judgment of them for the way they’re behaving. And in motivational interviewing, we do the exact opposite. We emphasize the patient’s autonomy and the patient’s right and privilege to make their own decisions.”
And the technique can work fast. It has even be used in emergency rooms, Zuckoff says, "literally where the physician is stitching up the patient and at the same time having a five-minute conversation about seat belt use or about alcohol use. It is that flexible and adaptable."
Still, many doctors don’t have an extra second to spare with patients, right?
Zuckoff says doctors who don't feel like they have time for motivational interviewing might want to consider how much time they're spending having the same conversation with a patient over and over again. Like a doctor who tells a patient at every checkup: "So Mrs. Jones, you’re 30 pounds overweight and here’s what you should do."
Chances are, Zuckoff says, Mrs. Jones will be doing what he calls "the bobblehead effect," nodding and smiling but with no real intention to change. And of course, the next time the doctor sees Mrs. Jones, her weight is not going to be any different and the same conversation will roll again. That sort of failure, he says, can leave doctors feeling frustrated and ineffective.
Several factors are converging to make motivational interviewing more popular in medicine, Zuckoff says:
• Rising recognition that chronic illness is a far greater problem for Americans than acute illness, and that lifestyle and behavior factors drive much of it.
• Health reform is moving medicine away from "fee for service" and holding doctors more accountable for patient outcomes, which often hinge on behavior outside the doctor's office.
• Mounting research shows that the patient-doctor relationship is extremely important for whether the patient follows recommendations.
Also, motivational interviewing — much like a better-known psychological method, cognitive behavioral therapy — has built an "evidence base" of studies that just keeps growing.
"There's been a strong reliance on the science of it," Suzuki says, "and it's not just derived from some theory, it's really based on testing whether it works."
For years, Suzuki was the only motivational interviewing trainer at Partners HealthCare, Boston's biggest hospital system. He's spoken to thousands of people about it in the last several years. But the demand for the training is so relentless lately, he says — from the HIV clinic to the obstetrics clinic to psychiatry and beyond — that it now takes four or five experienced trainers to meet it.
So did motivational interviewing work for Thrasher West?
Well, she liked Suzuki’s interview, she says — because nobody likes being told what to do: "This was different, because he was listening to me and he was hearing what I had to say. I might go home and not smoke."
That was on Friday. But the next Tuesday, she said she’d just smoked her first cigarette since getting home from the hospital, driven by the pain and stress of kidney dialysis.
Even after a good interview, Suzuki knows better than to expect instant miracles.
"It doesn’t mean she’s going to walk off into the sunset, a nonsmoker, and she’s never going to smoke again, I have no expectations about that. But it’s a clear demonstration that we can have a big influence on patient motivation in these very brief encounters," he says. "Number one is, just as she said, we take the time to listen."
Readers? For a sample of Dr. Suzuki using motivational interviewing for weight loss, listen to the beginning of the "Muffin Top" episode of our podcast, The Checkup, a joint production of WBUR and Slate. It's here.