Motivational Interviewing Techniques to Improve Psychotherapy Adherence and Outcomes for Patients With Psychogenic Nonepileptic Seizures

The gold standard for diagnosis of PNES is capture of all habitual event types on video-EEG, with history and semiology (signs and symptoms of the seizure event) consistent with PNES and with no epileptiform EEG abnormality immediately before, during, or following the events (11). The differential diagnosis includes epileptic seizures, syncope, complex migraines, sleep disorders, movement disorders, cerebrovascular injuries, metabolic derangements, and medication effects. Once the diagnosis is made, 90% of neurologists internationally agree that psychotherapy is the treatment of choice (12). Two small randomized trials of cognitive behavioral therapy–informed psychotherapy (CBT) have provided preliminary evidence that CBT is effective in improving PNES frequency and quality of life (13, 14). A large, fully powered, multisite randomized trial of CBT efficacy—the CODES trial—has completed enrollment and treatment in the United Kingdom, with results forthcoming (15). Published CBT regimens for the treatment of PNES exist and are widely used by neurologists, psychiatrists, and psychologists who specialize in this disorder (16–18). Observational studies also suggest that other psychotherapy modalities, such as brief psychodynamic psychotherapy, mindfulness-based therapy, group therapy, and biofeedback, may also be effective in treating PNES, but clinical trial data do not exist (19–23). Brief psychodynamic interpersonal therapy has also shown benefit in studies including mixed populations of participants with PNES and other FNDs (24, 25).

Unfortunately, there are many obstacles to evidence-based treatment of PNES, and most patients who receive the diagnosis do not complete any psychotherapy intervention (26, 27). The obstacles to treatment may be roughly divided into systemic obstacles, clinician-based obstacles, and patient-based obstacles (28). Systemic obstacles to treatment include a shortage of psychotherapists (29), driving restrictions (30), and poor insurance coverage of psychotherapy. Clinician-based obstacles include stigma, a general lack of knowledge about PNES and other FNDs (31), poor clinician-patient communication, and poor communication between the neurologists who diagnose PNES and the psychotherapists who provide treatment (32). Individual patient–based obstacles to treatment include a high prevalence of psychiatric comorbidities, such as PTSD, depression, anxiety, and personality disorders (27); alexithymia (an inability to consciously recognize and verbally describe one’s emotions) (33); poor social supports; and ambivalence about the diagnosis or psychotherapeutic treatment.

Ambivalence is the common state of experiencing simultaneous conflicting motivations (2)—for example, when we are simultaneously motivated to undertake an important work project yet are also drawn to relax with a procrastinatory activity such as watching TV. Legitimate motivations can pull an individual in two contradictory directions, as when those with PNES wish to treat their PNES so that they can care for their family members and are simultaneously reluctant to engage in psychotherapy that may involve discussing and thinking about traumatic memories and negative emotions. The discomfort of ambivalence can lead one to stop thinking about treatment altogether, perpetuating the status quo (2). Negative interactions with the health care system can also cause and exacerbate ambivalence, as when a clinician treats a patient in a disparaging or distrustful manner, leaving the patient feeling defensive or confused about the cause of the symptoms for which the patient was sincerely seeking help. Unfortunately, such behaviors by clinicians toward patients with PNES are extensively reported by patients and documented in the medical literature (34, 35).

Although we can reduce systemic and clinician-based obstacles to treatment through technological interventions such as teletherapy, training additional psychotherapists, and continuing education to reduce stigma, the individual patient–based obstacles to treatment can still present significant barriers. Even in a resource-rich quaternary care setting, with rapidly available psychotherapy and providers who are knowledgeable about PNES and committed to its treatment, nonadherence with psychiatric follow-up was shown to reach 76% within 6 months of initiation and 86% within 17 months (26). Moreover, nonadherence with psychotherapy is associated with worse treatment outcomes, including worse PNES frequency, quality of life, and emergency department utilization (27). Therefore, it is essential for neurologists, psychiatrists, and other psychotherapists to utilize effective interventions to address patient ambivalence and improve adherence to psychotherapy.

MI was developed as a patient-centered counseling style specifically to address the common problem of ambivalence about behavior change (2). MI has been demonstrated to be effective in helping people to change risky substance use behaviors and has also been adapted to promote adherence with numerous medical interventions for medical and psychiatric conditions (36–38). MI is efficacious in improving psychotherapy adherence specifically among patients with PNES and in other populations with high rates of nonadherence, such as adolescents with depression and anxiety (10, 39). Importantly, MI is deployed as an intervention to improve clinician-patient communication, to give patients a greater voice in considering and planning treatment, and ultimately to improve patient engagement and adherence with psychotherapy. MI is not in and of itself a treatment for PNES. Rather, it is a complement to CBT or other forms of psychotherapy and can be integrated within active psychotherapeutic PNES treatments when patients’ motivations for such treatments wax and wane.

MI differs from more didactic methods of health education and counseling in that it focuses on eliciting patients’ own reasons for changing their behavior, helping patients to explain these reasons in their own words, and transitioning from those reasons to formulating their own plan for change. Although the interviewer has a target behavior in mind, such as adherence with a specific medical intervention or psychotherapy, the process of MI involves a complex interaction between the patient and interviewer in which the interviewer primarily reflects the patient’s speech and unspoken but implied ideas, minimizing novel input and questions. Throughout the course of MI, there is an emphasis on the skill of reflective listening, in which the patient’s literal statements are repeated by the interviewer (“simple reflection”) or in which ideas suggested by the patient are stated explicitly by the interviewer (“complex reflection”). In either case, the goal is to elicit further “change talk” from the patient—i.e., statements that favor change, usually moving steadily in the direction of making concrete plans. Simultaneously, there is an effort to acknowledge but gradually deemphasize and resolve the patient’s statements opposing change (“sustain talk”). MI research has demonstrated that the resolution of the patient’s ambivalence, as manifested by an increased ratio of change talk to sustain talk, is correlated with the likelihood of subsequent behavior change (40). Another mechanism by which MI may improve engagement and adherence with psychotherapy among patients with PNES, is by promoting a more reflective and patient-centered communication style for clinician-patient interactions. This may result in patients feeling more heard, understood, and respected, thereby reducing ambivalence about the diagnosis and treatment of PNES.

The application of the methods of MI are applied across four sequential but overlapping processes: engaging, focusing, evoking, and planning (Table 1). A critical component of MI, which underlies all four of the overlapping processes, is the attitude or “spirit” of MI, which entails the interviewer’s commitment to collaborating with the patient, engaging and working with the patient as he or she is, and the interviewer’s belief that all persons have the capacity to change their behavior, no matter how ambivalent or opposed to change they may present initially (2). This stance supports curiosity about a patient’s perspective and the use of reflective listening to convey empathy and discover the patient’s motivations for change. Importantly, the interviewer’s willingness to meet and collaborate with the patient, regardless of his or her current beliefs and motivations, does not imply that MI is an undirected counseling style. MI is necessarily directed toward a specific behavior change, such as cessation of risky substance use or psychotherapy adherence. The interviewer utilizes all elements of MI (reflective listening, processes, and spirit) to more effectively enhance the patient’s movement toward behavior change.

The clinical vignette presented above highlights several obstacles that frequently arise during MI and strategies that can be used to overcome these obstacles (Table 2). Julia’s response to conventional didactic psychoeducation, when her neurologist, neuropsychiatrist, and social work therapist attempted to summarize PNES and recommend a treatment plan, demonstrates how somatic symptoms (in her case tinnitus and headache) can challenge the psychotherapeutic process. As illustrated in the vignette, one strategy for resolving such disruptions is using a more open and inclusive communication style, such as reflective listening, to increase patient control of and engagement in the communication.

The recurrence of Julia’s somatic symptoms during the transition from the evoking to the planning phases of MI illustrates the intense ambivalence that patients with PNES may have about making concrete plans for psychotherapeutic treatment. The reasons for this ambivalence may include discomfort with traumatic memories and negative emotions discussed during psychotherapy, negative prior experiences with the health care system, and other factors. Strategies for addressing this ambivalence illustrated in the clinical vignette include double-sided reflections, in which the patient’s reasons for avoiding behavior change are briefly noted before the patient’s self-stated reasons for behavior change are summarized and emphasized. The interviewer makes the patient’s ambivalence explicit while encouraging the patient to talk about the reasons for treating the seizures (change talk) rather than the reasons for avoiding treatment (sustain talk). Another strategy for managing heightened ambivalence around treatment planning is spending increased time evoking change talk prior to initiating the planning process. This allows the patient more opportunity to contemplate and state his or her reasons for engaging in psychotherapy and gives the patient greater control over what can be a particularly momentous and frightening decision to start psychotherapy. Using an ask-tell-ask framework to introduce SMART goals can be a respectful and nonthreatening way to introduce suggestions, such as the time-limited trial of psychotherapy suggested in the clinical vignette. This guiding strategy is often helpful for patients with PNES because they frequently assume that the only possible treatments are medications or surgeries. This strategy introduces the idea of trying psychotherapy, the recommended treatment for PNES, in a collaborative and nonthreatening manner that also respects the limited time available in typical clinical encounters.

Another commonly encountered obstacle among patients with PNES is a specific preference for neurological or medical interventions over psychotherapeutic interventions. Strategies for addressing this obstacle illustrated in the clinical vignette include close collaboration between the diagnosing neurological team and the treating psychotherapeutic team and the initiation of MI by the neurological team. Whether or not interdisciplinary clinics of the sort utilized in the vignette are available, close interdisciplinary communication (including direct verbal communication) and care coordination are essential for effective treatment of PNES. Finally, psychiatric comorbidities, including depression, anxiety, PTSD, and personality disorders, complicate treatment for the majority of patients with PNES (27). Close collaboration between the neurological, psychiatric, and psychotherapeutic team is again critical for addressing this challenge and can be enhanced through the use of a multidisciplinary MI study group to review and discuss cases. The vignette illustrates the benefit, when possible, of involving the diagnosing neurological team in supporting patient engagement and adherence with psychotherapy, directly through MI and indirectly through close verbal communication and collaboration with psychotherapists.