NURS 753 Week 3 WebEx Class Presentation 1 on Motivational Interviewing Example

"I Feel Duller on It": Motivational Interviewing for the Prescribing Psychiatric Nurse Practitioner When a Patient Wants to Stop Lithium

Slide 1: "I Feel Duller on It"

• Motivational interviewing for the prescribing psychiatric nurse practitioner
• NURS 753, WebEx Class Presentation 1

Speaker notes: Good evening. Tonight I will try to show, in ten minutes, how motivational interviewing works in the kind of visit we will have every week as psychiatric nurse practitioners: a patient who wants to stop a medication that is protecting them.

Slide 2: A Patient Who Wants to Stop

• 24 years old, bipolar I disorder, two hospitalizations for mania
• Stable on lithium for 14 months
• "I feel duller on it. I'm stopping after the semester."

Speaker notes: This composite patient is a college senior who has been stable for over a year. He tells us he misses the energy and creativity he had before treatment and plans to stop. Our instinct, which MI calls the righting reflex, is to warn him about relapse. Hold that thought; we will see what happens when we resist it. Notice also what he did not say: he did not say lithium is poison or that he is not ill. He named a cost he is paying, and that cost is where the conversation can begin.

Slide 3: The Spirit of MI

• Partnership, not expertise imposed
• Acceptance: worth, autonomy, affirmation, accurate empathy
• Compassion: the person's welfare first
• Evocation: the reasons are already in the person

Speaker notes: Miller and Rollnick (2023), who developed the method, define it as a collaborative way of talking with someone that strengthens the reasons for change that person already holds. Its spirit matters more than any technique. We are not installing motivation; we are evoking what the patient already has. Wheeler (2014) places the therapeutic relationship at the center of advanced practice psychotherapy, and MI is a disciplined way of practicing that relationship in a brief visit.

Slide 4: Four Processes

• Engaging: build the working relationship
• Focusing: agree on what to talk about
• Evoking: draw out the person's reasons for change
• Planning: commitment and a concrete next step

Speaker notes: The processes overlap and build on one another (Miller & Rollnick, 2023). With our patient, engaging means understanding what "duller" means to him before we discuss lithium at all. Focusing might be his goal of graduating and starting a design job. Evoking draws out his own reasons for staying well. Planning comes last, and only if he is ready.

Slide 5: OARS and Change Talk

• Open questions, affirmations, reflections, summaries
• Change talk: desire, ability, reasons, need, commitment
• Sustain talk: reasons to stay the same
• Reflect change talk; do not argue with sustain talk

Speaker notes: The core skills are open questions, affirmations, reflections and summaries. As we listen, we hear two kinds of statements. Change talk favors change, here staying well, and sustain talk favors the status quo, here stopping lithium. Our job is to notice change talk and reflect it back, so the patient hears his own reasons. Arguing with sustain talk tends to strengthen it.

Slide 6: Righting Reflex Versus MI

• Righting reflex: "If you stop lithium, you'll probably relapse."
• Patient: "Everyone says that. It's my life."
• MI response: "You've worked hard to stay well, and feeling like yourself matters a lot to you."
• Patient: "It does. I just don't want to lose my last semester either."

Speaker notes: In the first exchange, the warning is accurate but produces sustain talk and defensiveness. In the second, a complex reflection that affirms his effort and names his value of feeling like himself draws out change talk: he does not want to lose his last semester. That statement is a reason to stay well, and it came from him. The patient who hears his own reason for staying well hears it differently than when we say it.

Slide 7: Evoking and Planning

• Open question: "What happened the last two times you stopped?"
• Reflection: "So the semesters you lost were the ones without lithium."
• Key question: "Where does that leave you?"
• Options: dose adjustment, timing, symptom tracking, return visit

Speaker notes: He tells us he lost two semesters to mania. We reflect that, summarize his reasons on both sides and ask a key question. He says he would rather adjust than stop. Now planning is possible: we can review his lithium level and side effects, consider whether the dullness is depression or medication, and offer options while respecting that the decision is his. An MI-consistent clinician also provides information when asked, with permission. Here, that might mean explaining that dullness can sometimes be eased by adjusting the dose within the therapeutic range or by treating residual depression, and asking what he makes of that.

Slide 8: Why It Works

• Therapist MI skills linked to change talk, r = .55 (Magill et al., 2018)
• More change talk, less risk behavior at follow-up
• In schizophrenia, reflections and questions about adherence were followed by change talk about 70% of the time (Dobber et al., 2020)

Speaker notes: A meta-analysis of 36 studies with 3,025 participants found that therapist MI-consistent skills were strongly correlated with client change talk, r = .55, and that a higher proportion of change talk was related to reductions in risk behavior at follow-up, supporting the technical hypothesis of how MI works (Magill et al., 2018). Among patients with schizophrenia in a medication adherence study, reflections and questions about adherence were followed by patient change talk about 70% of the time, while affirmation alone rarely was, and a trusting, empathic relationship made those conversations possible (Dobber et al., 2020).

Slide 9: MI With CBT and Practice Points

• MI plus CBT may outperform CBT alone at posttreatment (Hastings et al., 2026)
• Use MI to open the door; use CBT and skills to walk through it
• Practice points: ask permission, reflect before informing, let the patient decide
• Discussion: Where does your own righting reflex show up in visits?

Speaker notes: MI is often combined with cognitive behavioral therapy. A 2026 meta-analysis of eight trials in problem gambling found that adding MI to CBT reduced gambling behavior and severity at posttreatment compared with CBT alone, though not at follow-up, and the authors concluded that the two work best when integrated thoughtfully rather than simply added (Hastings et al., 2026). In medication visits, I will take three practices from this: ask permission before giving information, reflect before advising and leave the decision with the patient. My question for you: where does your own righting reflex show up?

References

Dobber, J., Latour, C., van Meijel, B., Ter Riet, G., Barkhof, E., Peters, R., Scholte Op Reimer, W., & de Haan, L. (2020). Active ingredients and mechanisms of change in motivational interviewing for medication adherence: A mixed methods study of patient-therapist interaction in patients with schizophrenia. Frontiers in Psychiatry, 11, Article 78. https://doi.org/10.3389/fpsyt.2020.00078

Hastings, M. R., Forman, D. P., Kim, H. S., & Pfund, R. A. (2026). A systematic review and meta-analysis of the relative and complementary effects of motivational interviewing and cognitive-behavioral treatment for problem gambling and gambling disorder. Psychology of Addictive Behaviors. Advance online publication. https://doi.org/10.1037/adb0001186

Magill, M., Apodaca, T. R., Borsari, B., Gaume, J., Hoadley, A., Gordon, R. E. F., Tonigan, J. S., & Moyers, T. (2018). A meta-analysis of motivational interviewing process: Technical, relational, and conditional process models of change. Journal of Consulting and Clinical Psychology, 86(2), 140-157. https://doi.org/10.1037/ccp0000250

Miller, W. R., & Rollnick, S. (2023). Motivational interviewing: Helping people change and grow (4th ed.). Guilford Press.

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). Springer Publishing.