Motivational interviewing for adolecents ages 14 - 17
Motivational Interviewing is another method GPs can use when discussing alcohol and other drug use with patients. It assists you to find out where the patient is in the Stages of Change and target your intervention to where the patient is and to where they want to be.
It can help to identify the motivation behind a patient’s alcohol and other drug use, or what could motivate change by promoting engagement, minimising resistance and defensiveness and encouraging behaviour change.
Motivational interviewing is very useful with patients who are ambivalent about changing their substance use behaviour.
The core skills for good motivational interviewing are the OARS: Open, Affirm, Reflect, Summarise
- Asking Open questions
- Using Affirmation
- Listen Reflectively with:
- Simple reflections- avoid pressuring the adolescent for change and prematurely problem solve for them.
- Complex reflections- Discuss the good and less good things about problematic substance use
- Amplified reflections
- Double sided reflections
- Using Summarisation - with an emphasis on the less good things of greatest concern to the person
Let’s consider these one by one with an example of an adolescent girl who smokes marijuana with her boyfriend.
Open Questions: are used to open up the conversation with the patient. They allow the patient to explore their own motivations and behaviours, without the GP leading them to an answer. So rather than saying “I think you’re smoking weed because you’re stressed’ ask them ‘what have you noticed about the times when you want to smoke? Is there anything in common with them?’
Affirmation: acknowledges the way the patient feels and allows you to probe further. It is important not to affirm a patient’s ‘sustain’ talk- meaning any talk that favours continuing the status quo- like ‘I can’t give up weed because my boyfriend likes me to smoke it with him’. Instead an affirming response might be ‘I can understand why you want to spend time relaxing with your partner’.
Listening reflectively: is at the core of good motivational interviewing. Pick up on any change talk (like ‘I want, I could, I need’), and reflect it back to the patient, either as a simple reflection “So you’ve said you smoke because your boyfriend wants you to” or a complex reflection ‘it sounds like you smoke weed because your boyfriend is interested in it, and you want to make him happy, rather than because you want to on your own’.
You can also use amplified reflection, where you reflect back what a patient says in an exaggerated way. So you might say something like ‘I can tell you really value marijuana’, before bringing in a double sided reflection. A double sided reflection is when you use previous information to contrast against what is being said – for example ‘I can tell you really value marijuana, but you’ve also previously said that you wish you and your boyfriend could relax without it’.
Finally, motivational interviewing uses non-judgemental summarisation to demonstrate you have been listening and understanding the patient’s perspective, highlighting inconsistencies, and supporting them to move from ambivalence to determination. So here you would say something like: ‘Let me try and pull this together and you can tell me if I’ve missed anything important. You’ve identified that you mostly smoke weed with your boyfriend, because he finds it a great way to relax together. You really enjoy that time together, but sometimes want to be able to relax without it. Is that a good summary?’
Remember, with adolescent patients it’s useful to emphasise choice. A core skill in motivational interviewing is avoiding argument and rolling with patient resistance. Remember, as GPs we have the opportunity to see our patients at the next consultation where we can continue the conversation and support them at whichever stage of change they are at.
Let’s finally go through a consultation that shows the skills we have covered in both videos. Note when particular skills, like simple reflections, non-stigmatising language and confidentiality are brought up and you would incorporate your own manner and way to gain rapport or approach to better fit with your consultation style.
Remember, whatever the level of substance use, the first step is simply starting a conversation. As a trusted health professional, you might be the first one to ask about your patient’s consumption, identify their risk factors or really delve into their motivations for substance use. The health care system is also there to support you, and your patients. Together, we can help protect adolescents from substance-related harms
The fifth A is Arranging (follow up/referral) Care. There are youth specific alcohol and other drug services. You can call Alcohol Drug Information Service on 1800 250 015 or look up the Your Room website (yourroom.health.nsw.gov.au) to find out more. If you would like to talk with an AOD specialist about a patient, call the Drug and Alcohol Specialist Advisory Service (DASAS) 24/7 on 1800 023 687.