Psychopharmacology & Motivational Interviewing: The Art of Helping Treatment Stick

The weirdest part of clinical work is that the better your recommendation is, the more stuck a patient can seem. You listen, you assess, you explain the evidence, and then the plan quietly dies: the medication is never started, it is stopped without a word, therapy never happens, and the lifestyle change turns into another “I know, but.” I’m Dr. Saundra Jain, and this conversation is about a skill that helps treatment stick without turning the visit into a tug-of-war.

Motivational interviewing is not a model of psychotherapy. It’s a practical style of communication that helps patients explore their own motivations, work through ambivalence, and move toward behavior change in a way that feels collaborative. We dig into why persuasion often backfires, the “writing reflex” that pulls clinicians into fixing mode, and the science of reactance, how people protect autonomy when they feel pressured or judged. We also reframe “resistance” as something more human: fear, grief, exhaustion, and the conflict of wanting change while also wanting things to stay the same.

You’ll get concrete tools you can use right away in psychopharmacology and beyond, including the OARS framework (open-ended questions, affirmations, reflective listening, summaries), asking permission before offering information, and simple scaling questions that invite change talk. We also name what motivational interviewing cannot do, and how to stay respectful and direct when safety requires it. What’s one conversation this week where you can bring more curiosity and less persuasion?

Transcript

When Good Advice Goes Nowhere

Dr. Saundra Jain 0:05

Hi, and welcome to the human side of psychopharmacology. I'm Dr. Saundra Jain. Today I'd like to begin with the frustration that I suspect every one of us has experienced. You sit with the patient, you listen carefully, make a thoughtful assessment, and we draw upon years of training and clinical experience. You offer recommendations grounded in evidence and delivered with the very best of intentions. And then nothing happens. The patient doesn't start the medication, or they stop taking it without telling you. Or they don't follow through with your recommendations that they see a psychotherapist. They don't make the lifestyle changes they said they wanted to make. It's really about understanding what matters most to them, what might move them toward change, meeting them exactly where they are. And that's where motivational interviewing comes in. This episode focuses on an important question. How do we help treatment stick? Motivational interviewing, it isn't a model of psychotherapy. It's simply a style of communication. It's a way of having conversations that help people explore their own motivations, work through ambivalence, and move toward change in a way that feels collaborative rather than simply telling them what they need to change and how to do it. And in a field where so much depends on helping treatment stick, I think it's one of the most practical and important skills we can develop. Before we go further, let's consider three questions. One, why do good recommendations sometimes fall flat? Two, what if resistance isn't resistance at all? And three, how can we have conversations that increase the likelihood that treatment actually sticks?

How Motivational Interviewing Began

Dr. Saundra Jain 3:40

So let's begin with a little bit of history about motivational interviewing. Here's what's really interesting. Back in the early 1980s, William Miller noticed something that many of us have experienced ourselves. The more he tried to persuade people to change, the more they explained why they couldn't do it. Does that sound familiar to you? Rather than seeing motivation as something people either had or didn't have, Miller wondered if it was more fluid than that. Something that could strengthen or weaken, depending on how the conversation unfolded. A little bit like a radio dial. Our interactions and conversations with people can dial motivation up, or it can dial it down. Later, Miller and a colleague, Stephen Rolnick, they transformed those observations into what we now know as motivational interviewing. What began in addiction treatment eventually spread throughout health care because it turns out this isn't just an addiction issue, it's a human issue. We all know behavior change sits at the center of medicine. Whether we're talking about taking medications consistently, improving our sleep, reducing substance use, exercising more, improving our nutrition, engaging in psychotherapy, managing chronic illness. We are inviting patients to make difficult changes. And let's be honest, change is hard. It's hard for all of us. We are creatures of habit. The reason motivational interviewing has endured for more than four decades is that it consistently demonstrated value across a wide range of health behaviors and clinical settings. But it isn't magic, I'm not saying that. And it doesn't work for everyone. But here's what the evidence suggests that it can help people move toward meaningful change. And isn't that really what we want? And that's what our patients want too. Hundreds of studies and multiple meta-analyses have examined motivational interviewing across a wide range of health concerns and health behaviors, like smoking cessation, medication adherence, substance use disorders, diabetes self-management, weight management, and engagement in mental health treatment. You know, the effects are often described in research language as quote unquote small to moderate. But as clinicians, we understand that small shifts, baby steps, can have meaningful consequences. A slightly better conversation can strengthen our alliance with patients. And a stronger alliance can improve engagement. And we know improved engagement can support adherence, and adherence, it almost goes without saying, can influence outcomes.

Why Small Shifts Matter

Dr. Saundra Jain 7:49

You know, I'd like to name something that many of us don't talk about very often. I don't know a single healthcare professional who hasn't left an appointment wondering things like this. Hmm, did I miss something? Did I say the wrong thing? Was there another way I could have approached that conversation? We carry tremendous responsibility. We want to help. And when our best recommendations, our best efforts don't lead to change, it's easy to question ourselves. I think imposter syndrome visits all of us from time to time, even seasoned clinicians. Look, motivational interviewing doesn't eliminate uncertainty, but it does offer another way to think about these encounters. At its heart, motivational interviewing rests on a deceptively simple idea. People are often more persuaded by what they hear themselves say than by what other people tell them. And let's be honest, that includes us, all of us. It includes me. Like I said before, we are creatures of habit. Miller and Rolnick describe something within motivational interviewing that they call the writing reflex. It's our natural impulse to fix a problem or to set things right and to protect the people we care about. And honestly, I don't think that's a flaw in us as healthcare professionals. I think truly it's evidence that we care deeply. The challenge is that the stronger our impulse to persuade, to protect, the more likely patients are to defend the opposite position. And before we know it, we're in some ways arguing for change while patients argue for the status quo. It really is a familiar push and pull dynamic, one that often leaves both people feeling really frustrated. Motivational interviewing asks

The Writing Reflex And Pushback

Dr. Saundra Jain 10:32

us to pause before we rescue, to become curious before we become corrective. Think about that for a moment. To become curious before we become corrective. To pause before we rescue. Look, as clinicians, we're trained to diagnose problems, identify evidence-based treatments, offer recommendations. Patients are depending on our expertise. But sometimes, the more passionately we argue for change, the more passionately patients explain why they can't change. You're telling your patients, you really need to take this medication every day. And they respond by saying, I know, but we say you really should stop drinking. They respond, I know, but we also certainly I've said it a thousand times, you need to exercise. And I've heard, I know, but if you've been in healthcare for any length of time, you've probably heard enough yes buts to qualify for honorary membership in the yes but club. All right, joking aside, but it is true, most of us probably belong to that club ourselves. We know we should exercise more, get more sleep, eat differently, spend less time on our phones. Finally, clean out that closet we've been avoiding. And yet, change is hard. Not because we're lazy, not because we're resistant and pushing back, but because human beings are often pulled in two directions at once. Which

Ambivalence Is Normal

Dr. Saundra Jain 12:47

brings us back to one of the most important contributions of motivational interviewing. And that's understanding ambivalence. Ambivalence isn't pathology, it's humanity. Most people don't wake up fully committed to change. Part of us, we want things to be different, and part of us we want things to stay exactly the same. The patient who wants relief from depression, they may fear medication side effects. Or the patient who wants sobriety, they may fear losing a coping strategy. The patient who wants better health may fear failure. The patient who wants to take medication consistently, they may actually resent the daily reminder that they have an illness. Ambivalence doesn't mean someone lacks motivation. I want to say it one more time. All it means is they're human. Interestingly, motivational interviewing isn't simply a collection of techniques. Miller and Rolnick often emphasized what they called the spirit of motivational interviewing, partnership, acceptance, compassion, and evocation. Rather than telling patients why they should change, we help draw out their motivations and the strengths that they already possess. In many ways, the spirit matters just as much as the skills of motivational interviewing. There's also a bit of neuroscience embedded in this approach. Human beings are wired to protect autonomy. When we feel pressured, judged, or pushed, we often become more committed to the status quo. Psychologists call this reactance. It's the natural tendency to protect our autonomy when we feel pressured or pushed. Let's be honest, it's not just our patients. Most of us know exactly what that feels like. Motivational interviewing works with that reality rather than against it. I remember speaking

Reactance And Protecting Autonomy

Dr. Saundra Jain 15:39

with one of my patients who had been diagnosed with bipolar disorder. The patient knew lithium had helped stabilize his mood. He hated the regular blood draws. He really did not like the inconvenience. And overall, he hated what taking lithium represented to him. One day he said, Look, Sondra, I know it helps. I just don't know if I want to do this, take this medicine forever. I have to say it was tempting in that moment to respond with education, to remind him of relapse rates, previous hospitalizations, pull out the evidence. Now, I'm not saying anything against doing that because those conversations matter. But this is what motivational interviewing invites us to do. Become curious first. So maybe in response to where he was in that moment, I could have said, hey, tell me more about that. Or what worries you most? What feels hardest about this? I could also have asked, what do you see as the benefits of staying on treatment? In that conversation, what often emerges isn't resistance. It's not the pushback, it's grief, fear, certainly exhaustion, loss. And to tell you the truth, if I'm honest, I've been on the other side of this conversation. Living with type 1 diabetes now for maybe just a tad over 40 years. You know, in the beginning, I knew what I needed to do long before I was ready to do it. The more people pushed, healthcare practitioners, family members, and friends, I hate to admit it, but the truth is, the more they pushed, the harder I resisted. It took years for me to make peace with this diagnosis and to learn how to work with it, to befriend it instead of fighting it. You know, it's funny, change has a way of unfolding in its own time. And once we understand this dynamic, a very different conversation unfolds.

OARS Tools You Can Use Today

Dr. Saundra Jain 18:18

You know, one thing I want you to remember from today's episode are these four letters: OARS. It's a great way to remember motivational interviewing, elements of motivational interviewing. So O, open-ended questions, A for affirmations, R for reflective listening, and S for summaries. Now, OARS isn't motivational interviewing. These are communication tools that we can use in service of what we talked about earlier, that spirit of motivational interviewing. So let's take each of these one at a time, open-ended questions. These invite stories rather than yes or no answers. So instead of saying things like or asking things like, are you taking your medication? You might want to try. How has taking this medication been going for you? Instead of, do you want to quit smoking? Ask, what concerns, if any, do you have about your smoking? All right, let's look at affirmations. They acknowledge a person's strengths. So we might say things like, you've been carrying a lot and you're still showing up. Or I can see how much thought you've put into this. How about this one? You've made difficult changes before. These aren't empty compliments. Truly, they're observations about a person's resilience. All right, let's talk a little bit about reflective listening, because this may be the most powerful skill of all. Patients tell us who they are. They'll tell us if we're willing to listen. So you want relief from your anxiety, but you're worried about becoming dependent on medication. We might say part of you wants things to change, and another part isn't sure you're ready. Reflecting back communicates understanding. This is really important. These reflections slow the conversation down. And summaries help patients hear themselves. So for summaries, we might say things like, so let me see if I have this right. Or you're exhausted by how things have been going. We might say you want things to be different, or you're nervous about side effects. We could say, but you, but you also don't want to keep living this way. Sometimes hearing their own words reflected back really creates clarity for the patient. Here's another strategy I use often. That is asking for permission. So in a session, you might hear me say something like, Would it be okay if I shared some information? Is now a good time? Would you be interested in hearing what has helped some of my other patients? I might ask, could I offer another perspective? And of course, these are small shifts, these are baby steps. But I want you to know it changes the tone of the conversation. In offering this, we're communicating. I respect your autonomy. We're partners. This is shared decision making. We're collaborating together. Now, here's another practical tool. We could ask patients on a scale of zero to 10, how important is this change to you? Well, maybe they say four. Of course, we're not going to ask, why isn't it a 10? What we could respond with is, hmm, I'm curious, why a four and not a zero? Or you could also ask, what would help move you from a four to a five? And knowing what you know about your patient, you can modify that. What would help move you from a four to a four and a half? So we can, we can really be on the slow train in the conversations with our patients. And again, suddenly the conversation shifts from barriers to possibilities. Instead of defending why change isn't possible, patients begin articulating why change matters to them. So we'll start hearing patients say things like, I'm tired of feeling this way. I don't want my children to worry about me. I know I can't keep doing what I'm doing. And this is what motivational interviewing calls change talk. People don't usually talk themselves into change because we've given them better arguments. They change when they begin hearing themselves articulate why change matters. And decades of research suggest that the more our patients verbalize their own reasons for change, the more likely they are to act on them. I want to tell you about another patient. They said to me, Look, I know you want me to take this medication. And without thinking, I replied, actually more interested in what you want. There was a really long pause in the conversation. The patient said, I want my life back. I want you to know everything changed after that. The conversation stopped being about my agenda. It was now about hers. And that's where motivation lives.

What Motivational Interviewing Cannot Do

Dr. Saundra Jain 24:43

I want you to know it's important to remember that motivational interviewing, it's not a panacea. It doesn't eliminate things like structural barriers. It doesn't make difficult decisions easy. And it certainly doesn't guarantee change. It's not about abandoning expertise or avoiding difficult conversations or encouraging us to be passive. Look, there are times when we need to be direct. There are times when safety concerns will require immediate and direct action. But even in those situations, how we show up matters. You know, patients are more likely to engage when they feel respected rather than judged. Who wouldn't? More likely to be engaged when they feel understood rather than us trying to convince them. And certainly more likely to engage when they feel we're collaborating together rather than us telling what they need to do. What I've come to appreciate is that change rarely announces itself with great fanfare. More often it sounds like this. You know, I've never thought about it that way before. Maybe I'm more ready than I realized. Or something as simple as, thank you for listening. Certainly small shifts, but often that is how change begins.

One Small Change This Week

Dr. Saundra Jain 26:26

So this week, I'd encourage you to try one thing. Not all of ORs. It doesn't have to be a complete overhaul of your communication style. Just one thing. Ask one more open-ended question. Offer a reflection before giving advice. How about this one? Ask permission before sharing information. And notice what happens. You may discover that patients tell you more than they've told you before. You may discover that you're carrying a little less of the burden yourself. And if you are someone who leaves appointments wondering whether you said exactly the right thing, I want you to know motivational interviewing offers some reassurance. You don't have to have the perfect response. You don't even have to convince. You don't have to carry the entire burden of change on your own. Because motivational interviewing isn't about finding the perfect words. So thank you for joining me for this episode of the human side of psychopharmacology with Dr. Sondra Jan. Before we close, I'll leave you with a question. What is one conversation this week that might benefit from a little more curiosity and a little less persuasion? Okay, my friends, until next time, remember the medication matters, the diagnosis matters, the evidence matters, but every encounter is therapeutic. And how we show up matters.