and addiction psychiatrist in Charlotte, North Carolina. And this hour we're gonna talk about some psychosocial treatments of addictions. Some of this certainly can be used in other areas of medicine I actually just got some of the questions from the benzodiazepine talk and some of this would even apply to how you work with some of those patients that might be resistant to changes in medication. I still have no disclosures, excuse me. So we're gonna talk about really the impact of counseling on recovery. And there's some controversy around that I'd hope to clear up and then evidence-based practices. So I'm gonna go through cognitive behavioral therapies, contingency management and motivational interviewing, which are three of the most evidence-based therapies in the treatment of people with opioid use disorder, out with substance use disorders. So many of you might have heard this, it's a somewhat controversy, it's a controversy within our field to a degree. I was a part of the ASAM office-based opioid treatment guidelines and there was discussion around, do people need to know how to do therapy to be prescribing buprenorphine? No, not necessarily. But, and some were to the point of patients don't need therapy. These are the four articles that are most frequently brought up by some of the leaders in the field, David Foleyne, Roger Weiss, Walter Ling. And they were really looking at what is the effect of counseling on the efficacy of office-based opiate treatment and where does more intensive treatment fall into that? And these were, it's a graph of the various parameters of the study and also the results of the study. And the thing that I would point out, you're gonna get these on your slides, so I'm gonna go to the next slide that really points out some of the things that were important from this. Well, before I move on, just looking at the exclusions, the exclusions included no serious problems with alcohol, benzodiazepines or sedatives in the first FILEEN study, then no IV heroin use or serious problems with other drugs in the Roger Weiss study, no serious problems with other drugs in the Walter Ling study, no dependency on other drugs or serious psychiatric problems in the last David Foleyne study. So to be clear, that couple of different things, that all of these studies really did look at monitoring weekly the patients with, in a research protocol and monitoring urine toxicologies results. And the patients with either severe medical or psychiatric comorbidity were excluded. Positive outcomes favored patients with no injection drug use or minimal use of alcohol or other substances, which is not typical of a lot of my patients. And patients in office-based buprenorphine treatment, there was insufficient evidence to recommend for or against any specific psychosocial intervention in addition to addiction-focused medical management. And that was published in the VA guidelines. The choice of psychosocial intervention should be made considering patient preferences and provider training and competence. So what is medical management then? And I think that's important and something that I really wanted to clarify. So this is what you can find in the guidelines, which are really very good, that the guidelines with the veterans and the Department of Defense and substance use disorder guidelines. And it includes the fact that these are 15 to 20 minute sessions on potentially early on weekly. And as the patient, you know, stabilize to monthly sessions, monitoring the adherence to the specific treatment and adverse effects of the medication and education around alcohol abuse and opioid use disorders and the health consequences and treatments to those disorders. Encouragement to abstain from illicit opioids and other addictive substances and encouraged to attend and referral to community supports for recovery. And that might be a psychotherapist. It's certainly very often includes NA, NA meetings, AA, NA meetings and encouragement to make lifestyle changes to support recovery, understanding relapse prevention. So the patient management techniques in that regard are sobriety as a primary goal. Again, we're gonna talk about that a little bit in greater detail, particularly in the motivational interviewing section. But structured therapies work the best and those are cognitive behavioral therapy, 12 step facilitation, which is more a recovery treatment than it is acute treatment and then motivational enhancement therapy to achieve sobriety. And learn to work with AA and NA. Does, you know, certainly understand the tools of relapse prevention. Highly important and everyone should have exposure to that and can be done very nicely and very succinctly in medication management. Avoid excessive dependency on the program or a drug or, you know, the idea is to enhance the patient's internal skills to be able to get on with their life. And so in that way, even how the medication is taken and those sorts of things, it's important that they learn self-management techniques and integrate medication management into the recovery program and use the stages of change to guide that therapy. And I'll describe the stages of change. My guess is most of you had exposure to it before, but we'll be clear about it. So there are a variety of evidence-based practices that have been identified by the National Institute of Drug Abuse. They include cognitive behavioral therapy for a variety of substances, contingency management also for a variety of substances that includes motivational incentives and community reinforcement, which incorporates a lot of cognitive behavioral and contingency management skills and then motivational enhancement therapy. The matrix model was established by the University of Southern California and has been very instrumental in a set protocol for the treatment of patients with stimulant disorders. We've had a few updates of it. I'm not gonna go through all that. Most of it, I would say, it's largely dependent on cognitive behavioral therapies. Then there's 12-step facilitation that teaches patients how to use the steps in a way that will help them move forward in their lives. Again, there's been some controversy that many of you may know in treatment programs that jump right into 12-step meetings. Instead of establishing some ground rules, establishing some therapies that help stabilize the patient before they find themselves in a place where they're supposed to report on themselves and that sort of thing, that can be very difficult for patients initially and be very off-putting. A reason why they can drop out of treatment. NAAA has been profoundly helpful in so many people's lives, but it is a way to maintain their sobriety. It's a recovery technique more so than it is an initial treatment. And then family behavioral therapies that once again incorporate mostly the community reinforcement approach. So let me go through those more quickly. And that is we're gonna spend some time on cognitive behavioral therapy, contingency management, community reinforcement, and then motivational enhancement. And I'm gonna go through this more rapidly than you'd probably like, but we don't have a lot of time to cover a lot of material. So hang on and you will get all the slides. So cognitive behavioral therapy is a manualized individual therapy that was used in Project MATCH. And it's one of the places that you can get this information and have this tool. It's a public domain. And this, in the Project MATCH, it was 12 sessions, and it was built around cognitive and behavioral skills that you would want to try to establish in the patient. And it really saw drinking, because this was a project looking at alcohol use disorders, as a functional problem related to skill deficits. So certain things that needed to be learned in terms of skills in order to be better functioning in a way that they didn't necessarily turn back to alcohol to get on with their lives. And it did not involve people with other psychiatric disorders. Seeking safety, which many of you know, and those of you that don't, I would have you take a look at it, may very well be on the exam, and that it is, has been, you know, it is so clear that trauma is a huge part of the patients that we take care of. Either early traumas, traumas that took place while they were using a drug, or they resulted, they had a trauma that contributed to the onset of their drug use. And it is also a manualized therapy built around a lot of cognitive behavioral therapies or approaches, but really helps people work through various traumas that have taken place in their lives. It was designed around PTSD and the combination of that and substance use problems. It really focuses on first establishing a safe place for patients and all programs should be trauma informed. And that is setting things up in a way that people do not feel threatened by others in the group or, you know, either through language or body. And so no acting out, no substance use. And it combines, again, cognitive behavioral approaches to both disorders, that is the trauma and substance use problems. And it's useful for a variety really of dual diagnosis patients. Cognitive behavioral therapies, then, you know, those that I just showed you, really teach patients to modify their thinking and behavior related to their use, changing other areas of life functionally related to their use. So it helps people begin to track their thinking as it's associated to how they live their lives and other activities in their lives. They've learned to identify the feeling, the affect and behavioral consequences of the thoughts of the activities they've been involved in and increases the, and how that increases craving and episodes of use. Where were they? What were they thinking? You know, what was their feelings at the time? And cognitive behavioral therapy, cognitive model hypothesis is that people's thoughts and feelings are not determined by a situation. You know, we can all be in various situations and have different interpretations of it, but by the individual's interpretation and construction of that situation. So, you know, we showed that even in the cocaine pet scans that I showed you yesterday, where they put people in the pet scanner and showed cues and it lights up certain areas for the patients that had cocaine use disorders and not in those patients that didn't. So, and that's all how we interpret life. And cognitive behavioral therapy seeks to modify the dysfunctional core beliefs that result in automatic thoughts, which trigger emotions in any given situation. So the tools that they use include Socratic questioning, that is stimulating the self-awareness of the patient and focused on the problem definition, expose the patient's belief system, get them to really be thinking about, you know, how is my belief system different? I mean, one of the things that I often think about when I hear that, it's like young people saying, you know, well, everybody at my junior high school smokes marijuana. And for them to really begin to recognize that's just not true, unfortunately. And even though the group that they're associated with, that's what it is. And so it becomes, that's everyone. And challenges irrational beliefs, revealing cognitive processing. And so that they really start thinking through it. There's a lot of homework involved. There's some great tools that people can use to send people home to do, you know, between sessions. And then that can include self-monitoring, which can include diary work and self-monitoring, recording amount and degree of thoughts and behaviors, really starting to break it down and reveal these, you know, cognitive processes that are taking place. There can be, and are behavioral experiments where they have something, you know, you set something up for certain experiences and observing and reflecting on that experience and either in therapy or outside of the group. And systematic desensitization can take place when now you have this thing, and we do this a lot with anxiety disorders. You think about, you're starting to get anxious, then you analyze the environment in which you're experiencing this in, and why did you have that trigger? And then recognize that you are safe and then use skills to allow yourself to relax around that situation. And that results then in less of an anxiety response going into the same situation again. So patients then learn to the techniques to change thinking and behaviors that contribute to their use, that strengthen their coping skills, that improve their mood in general, because now they're not as frustrated or scared or anxious, and improves interpersonal functioning, because they're not as scared and anxious, and enhances social support. People begin to engage with them in a way that's more supportive. Treatment incorporates structured practice outside of sessions, including scheduled activities, you know, helping them think about positive things they could be doing, self monitoring, thought recording and challenging and interpersonal skills practicing. So when used with alcohol, three systemic reviews indicated that CBT is generally more effective than minimal or control models for individuals with alcohol use disorders. And it's not superior to, you know, to act not superior to active treatments. So it can be very helpful. Contingency management uses some of that, what we just talked about, but also uses reinforcement techniques. So it reinforces or punishes consequences to alter form and frequency of voluntary behavior. And it's known as operative conditioning. So this Skinner box, we're gonna have a train go by here. And the format to contingency is the format to contingency management behavior that is maintained in part by reinforcing biochemical effects of the substance, and secondarily, reinforcing environmental influences. So animals exhibit consumption patterns indicative of dependence and researchers can modify animals use of drug by reinforcing and punishing consequences. So that would be the, you know, this pressing the lever in the Skinner box, and they get another dose of cocaine. And but then the opposite would be an aversive reaction, losing something if they were to use or move in the box in a certain place. So animals will consume alcohol similar to humans. So there are rats that they've made alcohol dependent, and will compete complete cumbersome tasks to obtain and consume the desired substance and forego reinforcers like sweets or high calorie solutions that are basic substance to life. You know, we've all seen that, you know, people destroying themselves to continue to use drug. This behavior pattern is similar to that exhibited by alcohol use disorder dependent patients. Even in the face of addiction, the availability of alternative reinforcers can reduce alcohol and other drug use. So contingency management is a strategy in alcohol and other drug use disorders to encourage positive behavior change by providing reinforcing consequences when patients meet treatment goals. Those consequences are typically are often or more best if it's something that the patient chooses as important to them, withholding those consequences as a punitive measure when patients engage in undesired behaviors. So positive consequences for abstinence, therefore would result in a receipt of a voucher that is exchangeable for retail goods is an example. And negative consequences for relapse may include withholding vouchers, or an unfavorable consequence of some kind. Often, it's, you know, particularly if they've been doing well, they get to make three, you know, choices out of a bowl. Now they get to their back to making just one choice out of a bowl, and they have to work back up to making three choices again. So clinicians may initiate contingency management procedures through written contracts detailing the desired behavioral change, you know, what is, what do they want? And how can we kind of reinforce that durations of the intervention, frequency of monitoring, and the potential consequences of patient's success or failure. Monitoring through tox screens is one of the more frequent ways. So the four principles are regular testing, you need to stay on top of it, you need to keep the patient accountable and keep you, I had a therapist I worked with that talked about being a little man sitting on the patient's shoulder, you know, they need to, they need to begin to feel treatment as a part of their lives. And so when they make choices, they're thinking about that to a degree. There needs to be an agreed upon tangible reinforcer when abstinence is demonstrated. The reinforcer can be withheld when the substance use is detected. And there is a need to assist the patient in establishing alternative, healthier activities to complete, compete with the reinforcement derived from their alcohol or other drug use disorders. So, you know, we do try to help them think about what other things could you be doing? What things did you enjoy doing in the past? You know, what, you know, activities, sports, music, arts, just enjoyment of friends that that has been lost as your alcohol use has increased. So it's also includes incentives that establish, you know, that can be established in the take home medication. I would say I use it most frequently in moving people from one week prescriptions to two week prescriptions to a month prescriptions. That's a contingency management. You know, you've been doing really well, let's extend your script out of it, you know, and you can, you know, hopefully incorporate some of the other things. I mean, my patients are also grouped regularly. So some of the things that are going on there, but they don't, they can get a two week script. And in some ways, it's enhancement monetarily, because some of them have like a copay with their prescription. So it's really helping them in some ways. Financially, it's a reward that they that they establish larger quantities of buprenorphine, allowing more less frequent visits, increase in clinical privileges, money, I mean, this has been done with vouchers and various things, particularly in the VA vouchers for exchangeable goods in the quartermaster store, need not meeting a goal. An example would be positive drug screen may result in either no reinforcement or punishment. And the voucher amount is decreased or lower value or loss of take home privileges. There's a variety. Those are all contingencies that can help. It can just be unsettling for the patient enough to have them then thinking about what do I need to do so that I can keep moving forward and improve my, my privileges. All right. And reinforcement of medication compliance. So in some ways, this is how disulfiram works. You know, you take this medicine, if you drink, you get a punishment. And cognitively contingency management has been used to improve attendance in treatment, a study of parole conditioned patients, you know, they're all in control condition of being on parole, and alcohol use disorder showed that rewards for attendance to treatment compared to those without reward resulted in 90% of the reinforced group attended treatment regularly in a six month period, whereas only 11% really attended voluntarily. So what was the incentive for them to be there? So community reinforcement approach is, was originally designed around alcohol use disorders. And by Nate Asrin, in the early 70s, designed as an innovative treatment, the RA, around the idea that it is necessary to alter the environment in which people with an alcohol use disorder live, allowing for strong reinforcements for sober behavior from their community, including family, work and friends. So this is trying to bring a variety of environments together to help reinforce the patient's sobriety. It has subsequently been employed for other substances, it's based on operative conditioning, and incentivize, incentivizes patients, lifestyles, helping them to move towards a healthy lifestyle. So once again, it combines cognitive behavioral therapies with contingency management, and the community. So patient's movement towards the goals is reinforced each step of the way, focusing on progressive involvement in non-substance related, pleasant social activities, and enhancing the enjoyment they receive from the community by engaging family and job, you know, in their engagement in their work. Two offshoots of community reinforcement were based on similar operative mechanisms, adolescent community reinforcement, and CRAFT, the Community Reinforcement of Family Training, and which is a very, very common treatment protocol used for adolescents, and can be very, very helpful in working with kids, because so often it is their, their family, their peer group, that is so involved in whether they're going to do well or not. So basic procedures, you're really looking at external and internal triggers, what is their using behavior, short term positive consequences to their to their use, and long term negative consequences, that, that they can begin to understand and, and in this way, really look at it, how is it impacting their lives, their lives interpersonally, physically, emotionally, legal problems, job problems, whatever. And so it's initially there's an exploration of the patient's antecedents, positive and negative consequences to their use. This is like decisional balancing that we'll mention in motivational interviewing. This allows for identification of new behaviors, and there will be reinforcing in reinforcement of that, that will discourage their continued use of alcohol or other drugs. So they look at sobriety sampling based on counterproductive, you know, what's counterproductive, that they, based on counterproductive for therapists to tell clients that they can never drink again. That's really the idea of, you know, once again, seeing what the problem is, where the patient is in terms of their behavior, and not starting right off with you'll never drink again, because it can be a rather scary thought for a variety of people. And we probably all have that experience. It begins with a client's agreement to sample time limited period of abstinence, which is always very interesting. And I mentioned that in the alcohol talk that people think that they can do this. But when they really try to stay within the healthy drinking standards, they realize it was impossible, and they come in more motivated. Happiness scale, identifying all aspects of their lives, what's important, and not just their substitutes. So it's really trying to engage in identifying where the things that they, that they're missing now, and that could help them feel better. Then establishing the behavioral skills similar to SCBT, problem solving skills, communication skills, drinking refusal training, all those sorts of things. And it is, again, manualized job skills, training provides steps that are obtaining and keeping jobs. So they literally, in these programs, you know, case management will kind of go through interviewing and all kinds of things that they need to learn to be successful in obtaining a job, social and recreational counseling, again, looking at what things are they doing, what things that they used to enjoy doing, what would they like to get back into. And then relapse prevention, again, similar to cognitive behavioral therapies in terms of looking at their skills, their problem solving skills, specific relapse prevention techniques, relational counseling, how do they talk more effectively with people, and that's modeled in their relationship in the counseling that takes place in the in treatment, and each member of the, of this dyad, this group requests a minor change from their partner, you know, how do you say that? How do you, how do you move through some of the problems that have been created with, with the use of alcohol and other drugs, and daily reminder to be nice to smile once in a while to try to engage in positive relationships with with others. Alright, so that's that. Now we're going to spend the next 20 minutes going through motivational interviewing. And I, my guess is most of you had, and some of you a lot of training in this, but we'll go through the basics of what it is. So why don't have patients adhere to recommendations? Do they not understand the consequences of not following medical recommendations? I mean, God, you know, like, you know, if they just take this medicine, they do great. Patients are often tired of being told what to do, and practitioners are frustrated with not being able to affect change. Motivational interviewing is a tool for practitioners to facilitate adherence. So it's being used to help people take their blood pressure medicines and all kinds of stuff. So it was first used on around smoking cessation is where, where the biggest introduction took place, but then it's been used in mostly in substance use disorder patients. But again, it's been brand has branched out into all areas. It improves the patient's intrinsic motivation for change and engages them in active collaboration in their own health behavior changes. So motivational interviewing is patient centered approach to help individuals find and use their own motivation to make changes in their behavior. MI communicates compassion, acceptance, partnership and respect. And that's, that's what I'm going to talk about in terms of the spirit really of MI. So it's collaborative person centered form of guiding to elicit and strengthen motivation for change is, you know, Miller and Rolick's description of this. Miller really was the initiator back in the 80s. Rolick, Steve Rolick, and he got together in the 90s. And we're now on third edition of their book. So the spirit of MI is the patient motivation is affected from the moment they walk in the door, how are they greeted, you know, really setting up the office to be more empathic to recognize these people are coming in with all kinds of problems, they may have had problems just getting into the office, and all impact the patient's motivation, even in our everyday workflow, how things are set up. A central component of MI applies to all our jobs. It's a way of being with people. So some of the core of motivational interviewing was really established out of the work of Carl Rogers and really empathic listening and authentic desire to understand others and empower them to change. Do you really care if they make a change in their lives? And those of us that have had the opportunity to watch that change, it empowers our caring to see people change, because we've had an opportunity to see such profound changes that it can take place in a person's life if they get their substance use problems under control. So the essence of MI is the ability to be open to another person's experience without judgment. This can be frustrating in trying to work with people who don't seem to want to help themselves. But how can we engage them in a way to start to motivate, to create a little bit of a spark that they might want to start to make some changes and see that recovery from an opioid use disorder is not so daunting. And I think this is a great quote, and that is, every problem was once a solution. So opiates were once a great solution to a pain problem. But then it can become a problem in itself. And you can almost look at everything we do. Cars were a great form of transportation, but now they're creating all kinds of problems in our environment and that sort of thing. So we just need to be careful about where we're moving forward and why we're doing some of the things that we do. A reason why bad habits are hard to change, we use them to attempt to calm down or to relax or to cheer up or feel more connected or worthwhile. So these were all reasons why people started using drugs, but now it's become a problem. When patients seem unmotivated to change, to take advice and don't assume they don't want to change, they may want to change. They're just afraid of change, or they can't see through that what would change be like. No person is completely unmotivated. They're getting up in the morning. They're trying to maintain. They're trying to move forward. They have good days. They have bad days, even while they're using drugs. And we all have goals and aspirations, and it's the ability to tap into that individual goal or aspiration. The way in which we talk to patients about their health can substantially influence the motivation for change. So we try to build a relationship of non-judgment and trust, respect every change involves a loss. If I do this, I'm going to, you know, this, I won't have this anymore. I might not have friends I used to work with or use with. Ask how the patient would like things to be. You know, how could, you know, how can things change in a way that you would feel more positive about your life or your relationships or work? Let the patient decide if and when change is right and affirm the willingness to talk about change. You want to ask them, so now that we're at this place, can we talk about, you know, how we might get there or what change might look like? So the things that I would point out in terms of 10 things that interviewing and motivational interviewing are not, and again, you're going to have these slides and you can look at it, but I would point out it's not a way of tricking people into doing what you want. There's a little bit of passive-aggressive. Obviously, we have an idea, you know, they're coming to us or we know our skills and we know what their life could be without the use of alcohol or drug, but how they're going to get there, what goes on, you need to back off the idea that we're going to trick them into getting there. We're going to use their skills. It's not our trick, it's them. And it's not decisional balance, although this is part of the technique. It's not, you know, what are the pluses and minuses of this, and a lot of people, including myself, and it was more highly, you know, stressed in the early editions of motivational interviewing that you would talk through, you know, what are the pluses and minuses, but more when you talk about the pluses, there's the train. You're going to, they start saying positive things about their use, and that could be reinforcing their use. That could be more what's referred to as sustained talk. It's not cognitive behavioral therapy. It's not just client-centered counseling, and it's not what you're already doing. I really encourage you to look closely at what is this, and am I really adhering to motivational interviewing techniques when I talk to patients? So it includes collaboration between the provider and the client or patient, engaging the patient's ideas about change, emphasizing the patient's right to choose their own path. How we're going to get there is going to be largely upon, you know, dictated upon how you feel comfortable getting there and compassion and all the care that we get. So MI is the style of patient practitioner communication to resolve ambivalence and build motivation for behavior change. MI focuses on creating a comfortable atmosphere without pressuring or coercion for change so patients can feel comfortable to share their concerns or better understand their reasons for or against change, allows for more informed, intrinsic investment in these decisions, and does not provide patients with solutions or problem solving until they've made the decision for change. And that is in part because there can be ambivalence, and the concept of resolving that ambivalence is central to the motivational interviewing. An ambivalent person perceives advantages and disadvantages to both maintaining the status quo and initiating it, and there's this avoidance conflict theory that says if one moves towards a goal, they're, you know, they're giving up something else the more one perceives disadvantages of that goal. So the quicker they move there without really being sure that this is a good move, they can have buyer's remorse. You know, you walk into a store and a salesman, you know, you didn't plan on doing something, and they talk you into something that you weren't, you know, you weren't, that's not what you were looking for or the price that you were going to pay for, and you leave the store going, oh, my God, what did I do? And that's that moving too quickly and avoidance conflict theory. So ambivalence, it views ambivalence as part of the natural process of change, accepting change without a full consideration of the pros and cons can lead to this buyer's remorse and early relapse, and the role of the practitioner is to help patients resolve their ambivalence by emphasizing their ambivalence and not arguing for change. So it sets it up into the stages of change, which is important for you to understand, and that is pre-contemplation is not a time to start talking about, you know, what life will be like without, you know, or how they need to be on some medication to help them stop drinking, like maybe antibuse or something, or if they drink at all, they're going to get sick. No, they're not even sure they want to stop yet, and if you push them too quick, they're going to leave feeling very uncomfortable and start thinking more and more about how they want to have a drink, but move them towards that place of contemplation or ambivalence, and then as they get there, then preparation, action, then into a maintenance phase, and then there is always that potential for relapse, so they need to stay on top of it. They need to continue thinking about it. So these are the, you know, these stages of change in terms of a person not thinking about change. It's pre-contemplative. It's sort of denial, but denial, I would say, is different than, like, lying. It's denial because now they have drugs still infused in their brain, and they're perceiving the world differently, and they really don't see, amazingly, when we can see so many different problems that could be a result of their use, they don't see it, but then moving them towards contemplation, preparation, action, and maintenance. So patients need different counseling approaches during each stage. Earlier stages need to build their motivation and confidence for change, and later stages need more education about how to change and how to prevent relapse. Practitioners can access this stage of change as a measurement of the patient's motivation. Where are they, and what do I need to do with them in that stage? How do I need to stay in that stage, but maybe give them some ticklers about moving on and accessing the patient's motivation, the practitioner, to collaborate the counseling approach to the patient's level of change. So MI, again, is a way of being with people. It's a spirit. It includes a lot of empathy. So empathy is your understanding of how difficult this is, the problems that maybe occurred early on before the onset of their drug use disorder, and then all the problems that the drug use disorder has caused them. So phrases like, so you're pretty frustrated with trying to lose weight, or many of my patients also have difficulty fitting exercise into their lives. Understanding that their lives may be different in a way that are causing problems. Then we use these, the ORS, as an acronym for open-ended questions, stay away from yes or no. I often, with new patients, I'll say, you know, on your way in here, what was your thought of what you wanted to ask? What did you want to get out of this? What was the plan? And affirmations, statements of appreciation or understanding reflection, crafted as statements allowing a patient's elaboration. And I'll show you these and summarizing it. So open-ended questions, as I say, is staying away from yes or no questions. It's not a survey. It's understanding the patient. How do they formulate a question or a statement? It can give you tremendous input, allowing them to just talk for not a long time, but enough that you get a sense of who they are, where they saw the problem. Affirmations have to do with helping them understand, you know, that this is difficult, and you're kind of rewarding them for even making it into the office. Reflective listening has to do with very carefully listening to what they say, and potentially then either emphasizing it or reflecting on it, identifying what kind of statement have they made to better know whether it's sustained talk or change talk and these things that one would learn in doing motivational interviewing. But you can repeat what they said. If you get stuck in an interview, just say, what I just heard you say is such and such. You know, if you started daydreaming, but definitely if you didn't fully understand what they said, repeat it back to them. You may also do it in a way that just slightly rephrases it or adds a certain empathic reflection to it, reframes it in some way, and feelings or affect. You can amplify it. You can do things like ask them then if they've been only saying no, no, no, no, no, ask them, you know, well, it sounds like you don't really feel like your alcohol or drug use disorder has caused any problems in your life. Well, I wouldn't say that, you know, and then they potentially go on to say something, some small part, but something in which it allows them to see it differently. And then you summarize what you've heard. You summarize primarily the assets, some of the difficulties they see in making change, but then ask them whether they wanna talk about ways in which they could change, things that they could do. Resistance comes in a variety of forms. A huge part of motivational interviewing is to stay out of arguing with patients. It does no good at all. And to just step back and, you know, think about does my, you know, is my counseling style match their readiness for change? Am I pushing too hard? Am I dismissing feelings? Am I undermining it? Recognize your role in the development of an argument with the patient. You know, we're there, we're part of this diet. And reduce the resistance by reflective listening and pathic statements, focusing on building. You know, there's a variety of things you can do. I sometimes, if I feel myself getting angry, I'll say, you probably feel me getting angry a bit. I can only tell you that's only because I see the ability for you to change and it's frustrating that I'm not able to, you know, seemingly be able to help you towards that. And then setting an agenda, you know, starting to move towards what are the things that we need to establish this and assessing motivation and confidence that they may have for change. You know, where are that? So that they're not gonna have that buyer's remorse. You can use a higher or lower exercise. So if on a scale of one to 10, 10 being you wanna make this change today and one, you're not ready at all, where would you be? If they say a four, you don't say what would it take to get you to a 10, you say, oh yeah, so why a four? You know, it sounds like it's not a one. What are the things that you are thinking about that would be important for change? Provide medical feedback, you can show them lab work or things that are indicative of the problems that have, you know, occurred that you have real objective evidence of. And then in doing this, you're, you know, providing them some information and then a listening, some response from that. Always take a moment to listen to the patient. Always get a sense of, am I moving too fast, too slow? Where are they? What's their motivation in terms of trying to do this? And then give real advice. Advice to change and using I statements and that sort of thing. So there can be a variety of provocative questions to get them to do that. And this is part of screening brief intervention. This is the brief intervention part. So just to be clear, you know, I want you to know that brief intervention is, revolves around motivational interviewing skills. So that was a very rapid review of three very important therapies in working with patients with substance use disorder. And there's other references here and I encourage you to take a look at them. Good luck.

addiction psychiatrist

psychosocial treatments

counseling

cognitive behavioral therapy

contingency management

motivational interviewing

stages of change model

effective communication

opioid use disorders