In a perfect world, all of our doctors would be really, really good at something called “motivational interviewing.”
There are a million websites and books devoted to motivational interviewing, but here’s a super-quick synopsis (that might make an expert in motivational interviewing cringe): basically, it’s an in-depth, open-ended, non-judgmental conversation about health behaviors that draws out our own thoughts about our drug use/alcoholism/weight struggles, etc.
In fact, your doctor has probably used “motivational interviewing” with you at some point, with varying levels of effectiveness.
Questions like, “do you feel like your drinking ever puts stress on your personal relationships?” Or, “what do you think would be challenging about trying to lose weight?”
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When done well, supporters of motivational interviewing say it can trigger our own internal motivations. And sometimes, as a result, we actually seek real change.
Wayne State University psychiatry professor Steven Ondersma is a big believer in the power of motivational interviewing. So much so that he spent the first chunk of his career traveling around training physicians how to do it.
Then, he hit a wall.
“I was getting more and more skeptical of my abilities, or anybody’s ability, to really implant it into the healthcare system, and have it reproduce with fidelity,” he says.
"I was getting more and more skeptical of my abilities, or anybody's ability, to really implant it into the healthcare system," he says.
For one thing, he says, you can only do so much training. For another, doctors don’t have a lot of time in their day for in-depth screenings and open-ended "feely" questions.
“Some people can learn it very quickly and are masters at it. And some people, if they were ever to get good at it, they’d really have to work at it,” he says (which is motivational-interviewing speak for saying that some doctors are terrible at this).
So Ondersma started exploring a growing field called "computerized intervention. It's already being tested for everything from reducing violence, to screening for mental health issues, to getting high schoolers to just say no to drugs.
But Ondersma is especially interested in helping one kind of patient: pregnant women grappling with substance abuse, primarily marijuana, alcohol, smoking, and opioids.
How it works
Here's how it works in his pilot runs: the front desk gives every pregnant patient a tablet, or a link they can open on their smartphone to access the app. A 3-D animated guide walks them through a tailored intervention based on their initial responses about substance abuse.
“And it would ask you what you like about the opioid use, and why you use it, and what it does for you. And it could be, ‘I use it to deal with the pain,’ or ‘I use it to deal with the stress,’” he says.
"And then we’ll typically ask, ‘well, what are the less good things for you? What are the downsides?’ And we’ll offer a great big list, some of which they might see and say, 'you know, that one’s true. I might deal with a lot of stress with my family because of it. I might be spending more money on it than I thought. It might be inconsistent with my values. I might not really see myself as a person who does this when I’m pregnant, and yet here I am doing it.'”
"I might deal with a lot of stress with my family because of it. I might be spending more money on it than I thought. I might not really see myself as a person who does this when I'm pregnant, and yet here I am doing it."
Finally, that animated guide reflects back their responses.
Ondersma says the program might respond to the patient like this: "I get it, you use for this reason and that reason, and you're not really sure it's important enough to change. On the other hand, part of you wonders if it might be bad, and is also concerned about the way you've ended up using more over time."
If, at the end of their session, pregnant patients tell the app they want to change, it'll help them develop a plan, get tailored text messages after they leave, and run through some treatment options in their area.
“We’re not just coming in without having any understanding of what they’re doing, but we really know that they’re a reasonable person, and they’re doing something for a very good reason,” he says.
In randomized trials of pregnant women who smoke, Ondersma says the results are encouraging. Web interventions increased the proportion of women who were abstinent at their follow-up appointments. They don’t just tell the doctor they’ve quit smoking, he says, they’re actually less likely to have a breath monitor test turn up positive for recent cigarette use.
In the long run, Ondersma is hoping to build up a big enough study to look at web interventions and other substances, like opioids. The current software is being tested out at two sites in Wayne County, and there’s interest from Munson Medical Center in Traverse City.
“We’re investigating what he’s done down state, in Southeast Michigan, to see if it’s applicable and can be used here,” says Mary Schubert, executive director of Women’s and Children’s Services at Munson Medical Center. “He’s had some really good results. So we’d like to trial it here, and see if it will work for our patients. Our hypothesis is that it will work. And we’re going to start with a smaller population, see if it works, and then spread it out if it’s positive.”
Schubert says they’ve been looking for some kind of technological support and outreach for pregnant patients, since “most of our moms have some sort of mobile device.”
“If you think about when is a good time to stimulate change in someone’s life, pregnancy is a good time to do that,” Schubert says. “These moms love their babies. They’re very concerned about their babies. Most of them are pretty open with us, because they are concerned about their babies.”
But Schubert says any kind of intervention has to, above all, be non-judgmental.
"We have to be careful about being very respectful in working with those moms," says Schubert. "There’s a reason that they started on those substances in the first place. It may be the only area of their life where they have control over. So how can we help them?"
In full disclosure: Ondersma is also running a company that sells his computerized intervention services to other researchers. "I don’t take any salary but do have ownership interests," he says via email. "I’m trying to find an alternate source of funding so it can be free for research."
If you're pregnant and grappling with substance abuse, you can find a list of Michigan resources here and here. According to the state, pregnant women and moms get priority listing for treatment services, and if you're on Medicaid, you should be able to get immediate treatment.
