"Lithium Makes Me Feel Flat": Motivational Interviewing With a 24-Year-Old Musician Ambivalent About His Mood Stabilizer, With the Spirit, the Skills and the Evidence
[Student Name]
University of Phoenix
PMH/503: Psychotherapy For Individuals, Families, And Groups
Week 5 Assignment
[Instructor Name]
[Date]
The client is a composite written for a model paper.
Mr. S., a 24-year-old guitarist with bipolar I disorder, has been on lithium for a year after a manic episode that led to hospitalization, lost gigs and debt. He has been stable but tells me, "Lithium makes me feel flat. I can't write music. I'm thinking of stopping." This paper describes how I used motivational interviewing in response.
The Theory
Miller and Rose (2009) describe motivational interviewing as a collaborative, person-centered method for strengthening a person's own motivation for change, proposing that it works through two components: a relational component, the empathic spirit of the conversation, and a technical component, the clinician's differential evocation and reinforcement of the client's change talk. When people argue for change themselves, they are more likely to change; when they are pushed, they tend to argue for the status quo.
The Evidence
Lundahl et al. (2010) meta-analyzed 25 years of MI studies and found small but significant, durable effects across problem areas, including substance use and health behaviors, with MI performing as well as other active treatments while often taking less time. Hettema et al. (2005) similarly found that MI effects were substantial early and varied across providers and settings, and suggested that it may enhance engagement in other treatments.
If I argued for lithium, he would argue against it; the aim was for him to hear his own reasons.
An Annotated Excerpt
Clinician: "It sounds like you've been thinking about this a lot. Tell me what feeling flat is like." (Open question, inviting his experience.)
Mr. S.: "Like the colors are turned down. I used to write a song a week. Now nothing comes."
Clinician: "The music matters to you more than almost anything, and right now it feels out of reach." (Complex reflection, naming the value underneath.)
Mr. S.: "Exactly. But going back to the hospital scares me too."
Clinician: "You're caught between two things you care about: your creativity and staying out of the hospital." (Double-sided reflection, highlighting ambivalence.)
Mr. S.: "Last time I lost everything. The band kicked me out. I was sleeping two hours a night and spent five thousand dollars."
Clinician: "Being stable has given you something back." (Reflection of change talk about reasons to stay on treatment.)
Mr. S.: "Yeah. I got back in the band. I'm paying off the debt."
Clinician: "You've worked hard to rebuild. That takes commitment." (Affirmation.)
Responding Without Righting
The righting reflex, the urge to correct the client with facts, would have led me to list lithium's benefits. Instead, I asked permission: "Would it be okay if I shared some options others in your situation have considered?" He agreed. I explained that feeling flat can sometimes be reduced by adjusting the dose, checking thyroid function, which lithium can affect, or treating residual depression, and that stopping lithium abruptly carries a high risk of relapse.
Evoking His Plan
Clinician: "Where does that leave you?"
Mr. S.: "I don't want to go back to how it was. Maybe we could check my thyroid and see if a lower dose works?"
Clinician: "You want to protect your stability and get your music back, and you've got a first step in mind." (Summary, linking values and plan.)
The Plan He Chose
We check his lithium level, which is at the upper end of the therapeutic range, and thyroid-stimulating hormone, which is mildly elevated. With his psychiatrist's agreement, we lower the dose slightly within range and treat his hypothyroidism. He agrees to keep a mood and creativity diary and to call before making any change himself.
The Four Processes
Motivational interviewing is often described as moving through four overlapping processes: engaging, building a working relationship; focusing, agreeing on what to talk about; evoking, drawing out the person's own reasons for change; and planning, developing commitment and a specific plan. In this session, engagement came through open questions and reflections, focusing on his dilemma about lithium, evoking through reflections of his change talk and planning through his own proposal to check his thyroid and dose.
Sustain Talk and Discord
Mr. S. also voiced sustain talk, reasons to stop lithium, such as feeling flat. MI does not ignore sustain talk; it reflects it respectfully, which lowers resistance. Discord, tension in the relationship itself, would appear if he felt pushed. By avoiding argument, I kept discord low, which Miller and Rose (2009) link to better outcomes.
Why Ambivalence Is Normal
Ambivalence is not denial or noncompliance but a normal state in which a person holds reasons both for and against change. Many people with bipolar disorder consider stopping mood stabilizers, often because of side effects or missing the energy of hypomania. Treating ambivalence as expected, rather than as a problem, keeps the conversation honest.
MI and Medication Adherence
MI has been applied to medication adherence in several conditions, and its effects appear across problem areas (Lundahl et al., 2010). Combined with medical adjustments that address real side effects, it offers the best chance that a young person stays on a treatment that protects him.
What I Would Do Differently
Reviewing a recording with my supervisor, I noticed that I asked two closed questions early, which briefly narrowed the conversation. Replacing them with reflections would have kept him talking. MI skill develops through practice and feedback, often with coded recordings.
Follow-Up
We meet again in two weeks to review his diary, his thyroid treatment and his level after the dose change, and to ask how the plan feels to him.
Involving His Partner
Mr. S. lives with his girlfriend, who saw his last manic episode. With his permission, she joins a later session, where MI principles guide a conversation about how she can support his choice without nagging, which he says would make him want to stop.
Documentation
The note records his concerns in his words, the options discussed, the lithium level and thyroid result and his chosen plan, including his agreement to call before any change.
Safety Net
We also agree on early warning signs of mania, sleeping less and spending more, that would prompt a call, since any dose change carries some risk, and his girlfriend knows these signs as well and has the clinic's number saved.
His Music
We also discuss protecting his creative routine, such as writing at the same time each morning, which structure can support.
Why This Approach
Had I insisted, Mr. S. might have stopped lithium without telling me. By exploring his ambivalence and respecting his autonomy, the conversation kept him engaged and produced a plan he owned.
Conclusion
Motivational interviewing, grounded in a theory of relational and technical components and supported by meta-analyses of its effects, helped Mr. S. resolve his ambivalence about lithium. Reflections, affirmations and summaries evoked his own reasons for staying stable, and asking permission before offering options led to a plan he chose: adjusting his dose and treating a thyroid problem that may explain his flatness.
References
Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, 91-111. https://doi.org/10.1146/annurev.clinpsy.1.102803.143833
Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-analysis of motivational interviewing: Twenty-five years of empirical studies. Research on Social Work Practice, 20(2), 137-160. https://doi.org/10.1177/1049731509347850
Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing. American Psychologist, 64(6), 527-537. https://doi.org/10.1037/a0016830
How this PMH 503 Week 5 example is structured
The PMH/503 Week 5 work usually covers motivational interviewing and brief interventions. This paper presents MI's theory briefly, then shows it in action with an annotated excerpt, so the reader sees how technique serves the client's own reasons for change. Students search this week as PMH 503 Week 5, PMH503 Wk 5 or PMH/503 Wk 5; all three are the same assignment.
PMH/503 Week 5 questions, answered
What does PMH/503 Week 5 usually ask for?
Many sections ask students to explain and apply motivational interviewing, often with a dialogue excerpt showing its core skills.
What is the spirit of motivational interviewing?
Partnership, acceptance, compassion and evocation: working with the person, respecting autonomy and drawing out their own motivation rather than imposing the clinician's reasons.
What is change talk?
Statements by the client that favor change, such as desire, ability, reasons and need to change, which MI seeks to evoke and strengthen.
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