Welcome to the American Osteopathic Academy of Addiction Medicine's Essentials of Addiction Medicine, Introduction to Motivational Interviewing. My name is Dr. Gregory Landy, and I will be your host throughout this presentation. The course objectives for this Introduction to Motivational Interviewing are listed on this slide. As you go through this PowerPoint slide set, you will learn about motivational interviewing as it specifically applies to substance use disorders. You will also learn some basic skills and the principles and practices of motivational interviewing. And since many of the things we learn best we learn through observation, we will take advantage of that, and we will be watching a number of videos that will demonstrate some of the principles and practices that we've learned in the preceding slides. Please pay attention to these videos. They will help cement your understanding of the basic concepts of motivational interviewing. It's always useful to start with the definition of what we are going to be covering today. What exactly is motivational interviewing? Now, I must be frank. When I first heard this term, I had visions of late-night TV promoters trying to sell me the latest gadget. But that's not what motivational interviewing is all about. So take a minute and think about it. Exactly what is this? Well, you may be surprised to learn that motivational interviewing is actually a very specialized type of psychotherapy. In fact, this definition, motivational interviewing, is a patient-focused psychotherapy that seeks to resolve ambivalence about changing behavior. Now, that one simple definition has certain keywords that will help you remember the definition. It's patient-focused. It is a psychotherapy. Ambivalence is another keyword, and it's all about change. As we just noted, ambivalence and change are two of the keywords that are fundamental to understanding the definition of motivational interviewing. Another way to think of this is to remember the term inertia. Inertia is the resistance of any physical object to any change in its state of motion. So an object at rest prefers to remain at rest. And in many respects, you can think of human behavior in a similar fashion. Behavior that's been learned is one that does not want to change. It will resist change. On the other hand, behavioral change does occur, but it typically proceeds through identifiable stages. Motivational interviewing recognizes this in response to this fundamental principle that behavior tends to be fairly stable, but it can change, and it passes through specific identifiable stages. This will help us understand where our patients are in terms of change and how we can help them manage the process of adopting new behaviors. Motivational interviewing requires a basic understanding of the stages of behavioral change. Let's look at this slide for a moment. Individuals in the pre-contemplation stage are not planning to take any action in the foreseeable future. This is the stage that's most often equated with denial. Patients in this stage do not perceive their behavior as problematic. They see no need to change anything. In the contemplation stage, your patient may perceive they have a problem, and they may believe they should do something about it. Some of your addicted patients who do not appear to be ready for traditional treatment programs are in this stage. They recognize that they have a substance use disorder. They believe they should stop using the addictive substance, but they seem unable to do so. In the preparation stage, your patient has made a decision to change their behavior. They would like to do so fairly soon, usually within the next month or so. These patients are ready to enter into action-oriented treatment programs. The action stage refers to that behavioral stage of change, during which patients make, with your help, specific changes in their behavior. In the case of substance use disorders, abstinence is the generally agreed-upon behavior that signifies the action phase. Maintenance is the period after action, during which the changed behavior persists, and the patients work toward preventing relapse. Maintenance often requires a longer, sustained effort than your patient may anticipate, and failure to continue with maintenance behavior is a common cause of relapse. Finally, relapse is considered part of the continuum in the stages of change. So while relapse does not have to occur, if it does occur, it's seen as one of the stages of change from which the individual can restart their commitment to a life without substance use. Before proceeding further, it's always useful to examine the evidence for motivational interviewing. The Cochrane Collaboration conducted a systematic review, broadly looking at motivational interviewing for substance abuse. This particular systematic review was a meta-analysis based on 59 studies, with a total of over 13,000 participants. Very broadly, the results showed that people who have received motivational interviewing have reduced their use of substances more than people who have not received any other specific treatment. Now, as is the case with most studies, additional research is necessary, particularly those studies that examine other psychotherapies and have high quality data design. Another systematic review conducted by the same group looked at motivational interviewing for smoking cessation. The authors of this particular review looked at 28 studies involving over 16,000 study participants. The authors found and reported that motivational interviewing appeared to help more people quit smoking and brief advice or standards of usual care when provided by general practitioners and by trained counselors. As noted on the slide, these interventions were delivered by primary care physicians, hospital clinicians, nurses, and counselors. Interestingly also, the authors reported that a 20-minute session was more effective than longer sessions, and a single session of treatment appeared to be better received than multiple sessions, although both had good outcomes. So in summary, when motivational interviewing is used for smoking cessation or by extension in more specific substance use disorders, it might seem reasonable to conclude that it is a very effective psychotherapeutic intervention as part of a total treatment plan. So far we've looked at a definition for motivational interviewing and we've looked at the evidence basis for the practice. But now as we turn our attention to the clinical practice, we have to keep several things in mind. It's important to remember that in terms of substance use disorders, as many as 70% of your patients are in the pre-contemplation or contemplation stage when presented with a diagnosis of a substance use disorder. That means, in practical terms, that resistance to change is going to be a key factor that you as a clinician will have to navigate. You just completed a thorough clinical evaluation of your patient and all the evidence suggests that your patient has a substance use disorder. You're thinking about how you're going to present that diagnosis to the patient and you fully anticipate there will be a defensive response. You know that 70% of your patients are going to be in the pre-contemplation or contemplation phase and are going to be resistant to change. But given this high degree of potential patient resistance to your substance use disorder diagnosis, what can you do? Presenting a substance use disorder diagnosis to a patient is probably one of the more difficult dilemmas we as clinicians must deal with. Here we have an acronym, the death glossary. These are pitfalls to avoid when presenting the diagnosis to your patient. Before we go into these in a little bit of detail, let's review what the death acronym stands for. The D stands for drinking. The E for etiology. The A for arguments. The T for threats. And the H for hedging. That is the acronym, death glossary. Pitfalls to avoid when presenting the substance use disorder diagnosis to your patient. So let's go into a little bit of detail. The D, drinking or drug use details are not relevant. Patients will often give long and complex explanations for their drug or alcohol use and why they do not have any particular problem with it. It may be necessary to interrupt those explanations and help your patient move on. In addition, patients who are obviously intoxicated, they cannot process the information given to them and it may be appropriate to reschedule them and ask them not to drink prior to that next visit. E stands for etiology. Patients may try to elicit or provide an explanation for their addiction. It's unlikely that this is going to be useful. Just as with treating other chronic illnesses without clear etiologies, it's important to focus on the evidence that you've gathered for your diagnosis, your plan for treatment, and not be distracted by theoretical discussions about what caused the individual to end up with a substance use disorder. A stands for arguments. Arguments between you and your patient can seriously damage the patient-physician relationship and these should be avoided at all costs. Remember, motivational interviewing is all about respect and support and these are your best defenses against these arguments. The T stands for threats. Threats are a serious cause of damage to therapeutic relationships. Threats can include things like guilt and shame and they do not help promote recovery, but they do damage your relationship. And the H stands for hedging. Although arguments are detrimental, there should be no hedging on the diagnosis. You've reviewed your clinical evidence, you've done a comprehensive assessment, and your diagnosis is accurate to within a degree of medical certainty. If the patient appears unable to accept the diagnosis, an agreement to disagree should be made as well as offering the patient another appointment to continue the discussion. As I mentioned at the beginning of this PowerPoint slide set, we would be reviewing a number of video vignettes to help us understand motivational interviewing. What follows are three clinical vignettes. Look at each one. See if you can figure out what pitfalls the clinician stumbled into when they presented a substance use disorder diagnosis to their patients. Doctors, nurses, and physician assistants all have opportunities to counsel patients about health-related behaviors. As a medical professional, you have a responsibility to talk to your patients about tobacco use and how it affects their health. At times, you will also have a responsibility to talk to them about how second-hand exposure to their tobacco smoke affects other people's health. These can be sensitive topics, and it is important to keep in mind that the way you approach your patients about these issues will have a big impact on how your advice and concerns are received. In general, it is not useful to confront or scold your patients about their tobacco habits, as that approach is usually not well received by patients and may interfere with your ability to counsel them effectively. Watch what happens as this provider becomes more and more confrontational in her warnings about tobacco use and her advice to quit smoking. Okay, so I wrote a prescription for an antibiotic for Aiden that should help with the ear infection, but in looking through the chart, I mean, it seems like he's had six or seven of these just in the past year or so. That's really a big problem. Yeah, it's pretty stressful for both of us. It gets really upset. Well, one of the primary risk factors for multiple ear infections in kids is actually smoke exposure. Are you smoking? Yeah, I do smoke, but I don't smoke around him. I try really hard not to smoke around him. Well, the fact that he's having these ear infections is indicating to me that he is being exposed to smoke, and so what can you tell me about that? I don't know. I mean, I try really hard not to smoke around him. I don't smoke in the car. When he's home, I go outside to smoke. I just, I mean, I know it's bad, and I know it's bad for him, so I don't want him to be around it, so I try really hard. I really need you to quit smoking, both for your health and for Aiden. Do you know smoking around your child is associated not only with ear infections, it could get to the point where you have to put tubes in his ears pretty shortly here, but also things like vitamin C deficiency, cavities, like dental cavities, behavior problems, asthma, other upper respiratory infections. It's really putting him at a lot of risk. In addition to that, kids of smokers end up smoking themselves. Do you want him to grow up to be a smoker? No, but I don't smoke. I've thought about quitting, but it's really hard, so I just don't know how to do it. Well, now's the time to quit. It's really gotten to the point where you can't keep smoking. Not only for him, like I said, but also for you. You're putting yourself at risk for lung cancer, for emphysema, for oral cancers, for heart disease, for all kinds of things. I know, I know. I've heard. People have told me before. I've heard all that. I just don't know how to do it. How am I supposed to quit? It's so hard. Well, there's all kinds of things you can use now. It's not as hard as it used to be. You can use nicotine replacement. There's patches. There's lozenges. There's gum. There's the inhaler. There's nasal spray. We can talk about medications. You can try Chantix. You can try Zyban. There's quit smoking groups you can go to. There's hotlines you can call. I just don't have time for any of that. There's no reason why you shouldn't be able to quit. This is really important. I understand that. I know it is. I mean, everybody has problems, right? It's just really, it's really, really hard. Well, what can be more important to you than the health of your child? I don't know. I really need you to tell me that you're going to quit smoking. This is really important. I'll go look at all those things and I'll find, I guess I'll try to find something and I'll talk to my doctor about it. Okay. Well, I think you really need to think about this seriously. Like I said, it's really putting yourself and your child in danger. Okay. Whatever. Okay. Okay. By starting the interaction with an accusatory question, Are you smoking? The provider immediately put this parent on the defensive and minimized the likelihood of a productive discussion. She then proceeded to lecture and scold the parent repeatedly while ignoring the parent's multiple remarks regarding her low confidence in her ability to successfully quit smoking. Once the parent felt completely defeated, she caved in and announced that she would quit smoking. It is clear to any observer that this parent had no intention to quit smoking at this time, but rather that she was simply attempting to bring an end to the uncomfortable confrontation. In this case, the provider wasted an excellent opportunity to work with a mother who was expressing a real desire to quit smoking coupled with a lack of confidence in her ability to do so. By listening to what the parent was really saying, the provider might have been able to help this parent develop a workable plan. In addition, both the provider and parent would have felt more satisfied with the interaction. You had a serious car crash. You're lucky you didn't kill yourself or somebody else. What do you intend to do about that drinking problem? What drinking problem? Look, I had a couple of beers with my friends, that's all. Your alcohol level was 190. Clearly, you had more than a few beers. Now, how much do you really drink each day? Look, I had a few beers with some friends of mine after work. What's the big deal? Everybody does. I work hard, and having a couple of beers helps me relax after a hard day. It's time I got a little careless, that's all. Let's not make a big deal out of nothing. Just finish sewing me up so I can get out of here. Look, I'm in here, Doc, and I think I know when somebody's an alcoholic. I think you have a serious drinking problem. You better straighten it out. You can get out of here as soon as I stitch you up. But in the future, do not drink and drive. Have some sense. Next time, you might not be so lucky. Mr. Wilson comes in for his annual physical. On his annual substance use questionnaire, he scores at high risk for his alcohol use. Watch how discord develops between the provider and patient and how they reach an impasse. Mr. Wilson, your physical exam turned out just fine, so we'll keep an eye on the stomach problems that you described today, and as soon as your lab tests come back, our office will be in touch with you, okay? Okay. I did notice that you filled out our alcohol questionnaire, so we'll need to go over that before you leave. Let me just verify some information real quick. What is it that you typically drink? Just beer, regular beer. Just beer, so a standard 12 ounces is a standard can or bottle. That's what you're drinking. How many days a week are you drinking? I guess about three on average. About three days a week. And how many beers on the days that you drink? Usually four or five, maybe a six-pack. Okay. So up to six drinks on the days that you're drinking, about three days a week. Yeah, I'd say that's about right, yeah. Yeah? So based on that information that you told me, and then looking over your questionnaire here, I have to tell you, for a man your age, you're in a high-risk category. Really? For falls, accidents, other health problems, that sort of thing, developing in relation to your drinking, what do you think about that? Well, I wasn't aware of that. I don't drink that much. I like drinking with my friends on the weekends at home. Some of my friends really do have a problem with drinking, but I don't think I do. Well, in my professional opinion, you're really not too far behind your friends if you say that they're having some problems. You've come in today complaining about the stomach problems, and unless you're willing to quit or at least cut back, those problems are bound to just get worse. So what are your thoughts about that? I don't know what to think about that. This is news to me. I think I just need a pill for the indigestion. Can't you just give me one of those purple pills? Mr. Wilson, I could just give you a prescription and send you on your way, but again, unless you're willing to change your alcohol drinking. Quitting would be optimum, but at least cutting back. Then chances are you'll end up back here, and we'll just be having the same conversation again. Okay. Well, just give me the prescription, and I think I'll be fine. Okay. This presentation is substantially based on SAMHSA's Treatment Improvement Protocol No. 35 entitled Enhancing Motivation for Change in Substance Abuse Treatment. This particular Treatment Improvement Protocol offers guidelines to help you influence the change process in your patients by incorporating motivational interventions into your substance abuse treatment plans. This particular tip, No. 35, is available free from SAMHSA, and I would highly recommend that you obtain a copy. Let's take a look at two new videos examining motivational interviewing in clinical practice. In these two examples, the clinicians have learned how to apply motivational interviewing. Watch what happens this time when the provider cues in to what the parent is saying, empathizes with her situation, and attempts to work with the parent to find a solution that fits her needs. So I wrote a prescription for antibiotics for Aiden. Okay. I did want to talk to you, though. I'm a little bit concerned looking through his chart at how many ear infections he's had recently, and I noticed that you had checked the box that someone's smoking in the home, so I was wondering if you can tell me a little more about that. Well, it's just me and him, and I do smoke. I try really hard not to smoke around him, but I've been smoking for 10 years, except when I was pregnant with him. But everything, it's so stressful being a single mom and having a full-time job, and so it's just, that's why I started smoking again. You have a lot of things going on, and smoking's kind of a way to relax and de-stress. Yes, yeah. Some people have a glass of wine, I have a cigarette. Sure. And it sounds like you're trying not to smoke around him. Why did you make that decision? I know it's not good for him. I mean, I've read those things about ear infections and asthma and stuff, and that. But other kids have ear infections, and their parents don't smoke. So on the one hand, you're worried about how your smoking might be affecting him, and on the other hand, you're not so sure if it's really the smoking that's causing these problems. Right, yeah. I mean, he doesn't have asthma. He hasn't had a lot of other problems that his other friends have. And I've thought about quitting before in the past, but I just don't see how it's possible right now. What made you decide to quit smoking when you were pregnant? Well, he was inside me, and we were sharing everything, and I knew that he would get some of that. And I just didn't think I could live with myself if something happened to him. Right now, though, it feels almost too difficult to even manage or even to try. Yeah, exactly. How were you successful when you quit before? I don't know. I think about it now, I don't even know how I did it. I just did it. I just couldn't imagine him not being born or going into labor early and him having problems and stuff like that, all the stuff that they talk about with women who smoke. So that was just enough to say, okay, you know what? I'm not going to risk that. The risks were so scary then that you were able to stop. They don't feel as scary to you now. No, I mean, we're two separate people. Like I said, I try really hard not to smoke around him. I'm pretty good about that. I don't let other people smoke around him. So, you know. You're doing the best you can do. Yes. Okay. But it sounds to me, too, like part of you really does want to quit. Yeah, I know that I need to, and I keep, every new year I say, okay, this year I'm gonna quit smoking. But then something happens, and it just doesn't. It's on your to-do list, it's just not making it to the top. Yeah. If you did decide to quit, on a scale of one to 10, where one is not at all confident, you don't think you could do it, and 10 is you feel pretty certain that you could, where do you think you fall right now? Probably like a five, kind of in the unsure area. I know I've done it before, so I know I can do it, but at the same time, it just seems really hard, and it's not the same situation. Well, what made you say five rather than two or three? I know all the ways it's bad for me, and I don't want him to grow up thinking that it's okay to smoke. I don't want him to use any kind of, I don't want him to chew or anything like that. So I know I need to, especially before he gets old enough to understand what mommy's doing, but I just don't know if I can do it. Okay. So it sounds like you have a lot of reasons why you'd like to quit. You have been successful quitting in the past, and right now you're just feeling a little bit hesitant about your ability to do it. Yeah. Where do you think we should go from here? I don't know. I'd like some help. I just don't know what kind of help I need. Sure. Well, if you'd be interested, that's something I can definitely talk to you about. There are a lot of new options that can actually help people be way more successful in their attempt at quitting. There's different medications you can try. I don't like medicine. Okay. There's also a lot of support groups and classes that you can take where you have other people to go through it with you, and sometimes just having that support can be a big part of it, especially for people like you where smoking is such a stress reliever. That sounds nice, but I'm not sure if I have the time for all that. Sure. It feels like something that would take up a lot of time and maybe not fit into your life. I wonder if we could talk about some options that might fit into your life. That would be really nice. Okay. Well, if you're willing, then we could set up another appointment where you could come in and we could talk more about that. I would like that. That would be great. Great. Thank you. Sure. This time, the provider had the same agenda, to talk to this parent about the dangers of secondhand smoke and to counsel her to quit smoking. However, this time the provider's focus was on the parent's own view of the issue. By giving the parent an opportunity to reflect on her situation, the provider was able to elicit reasons for change from the parent herself. There was no need to lecture or scold because the parent was making her own case against smoking. Many times, our patients already have the information that we try to give them. What they really need is someone to listen to them and to help them sort out a plan that will fit in their life. By accepting and respecting our patients, even with their faults, we communicate our genuine desire to help them make positive changes in their lives. During this interaction, the provider demonstrated that she understood the parent's struggle and that she still wanted to help. As a result, this single parent found she finally had someone on her team. This increased both her interest and willingness to try working further with the provider to find a solution that would fit in her life. Mr.. Wilson comes in for his annual physical on his annual subscription use questionnaire, he scores at high risk for his alcohol use. Watch how this provider uses motivational interviewing throughout and leaves the door open for future conversation. Mr. Wilson, your physical exam has turned out just fine. So the only thing we're going to keep an eye on are those stomach problems that you came in talking about today. We'll touch base on those again real soon. The labs that we drew today, our office will get in touch with you about the results of those, okay? Okay. Now before you leave, I did notice that you filled out the alcohol questionnaire. Is it all right with you if I take a look at that and go over it with you? Sure. Okay, thank you. So we'll talk about this in just a minute, but first let's make sure we're on the same page. What is it that you do drink? Beer, wine? Just beer, yeah. Okay, so just beer. Picture here shows you that a standard beer looks like this. It's about 12 ounces. So that's what you're drinking? Right. How many days a week do you drink? I guess on average about three most weekends. So you're drinking on the weekends, so about three days a week. And on each of those days, how many do you typically drink? Four, five, sometimes a six pack. No more than that. Okay, so up to six beers three days a week, about 18 beers a week. Okay, so based on that information and then this questionnaire that you filled out, give me just a second. Okay, and this does provide us with some information just to offer you as some feedback. Would you like to get those results now? Sure. Okay, well your score on this questionnaire was a 15, so I have a card that helps us understand that. So you can see here that a score of 15 actually places you in this high-risk category. Yes, sir. And this could be that you're at high risk for accidents, so something like falling, that sort of thing. It can place you at a higher risk for health problems, like damage to your digestive system. So what do you think about that? Well, I wasn't aware of that. I know that I like to drink with my friends and enjoy their company and sit around on the weekend at home, relaxing and drinking beer. Some of my friends really have a drinking problem, but I don't drink like that. I don't ever get drunk. So you've noticed some problems that other people have from drinking, but for you this is all pretty new and surprising information. Well, I do have a little bit more information, if it's okay if I share that, about alcohol and its relation to health. Okay, so my concern is that the alcohol that you're drinking at the level that you're drinking, it could be in direct relation to the stomach problems that you're talking about today. What do you think about that? Well, I'm not sure what to think about. It never occurred to me that they could be related. And there's some good parts about drinking alcohol for you. You said that you enjoy drinking with your friends and on the weekends it's a way to just really help you relax at home. Exactly, yeah. So what, on the other hand, are some of the not so good things about drinking alcohol for you? I can't think of any. You know, I don't get drunk. I don't have hangovers. I just relax and enjoy it, so I don't know of any problems associated with it that I'm aware of, at least not so far. Okay, so at this point in time you see no real reason to change your drinking behavior at all? Not really, no. Okay, so one more piece of information, if it's okay, I share with you. It is recommended when a gentleman your age comes in drinking at the level you're drinking in, in this high-risk category, what's recommended is that you actually try and cut out drinking altogether. Now, of course, what you decide is up to you. Just curious about what you think about that. Well, I just don't see where that applies to me. Okay, so right now there's no real correlation and it sounds like no real incentive for you to quit, and again, what you decide is up to you. I've given you the information about the concerns and just what the recommendation would be, and before you leave today I could just give you some information to take home as a reminder to review, if that's okay. Yeah, that'll be fine. Okay, well thanks for having this discussion with me. I'm glad that your exam turned out great, and like I said, we'll just keep an eye on those stomach problems, okay? Okay, great. Thank you. Thank you. SAMHSA's Treatment Improvement Protocol Number 35 helps clinicians understand the changes in their addiction medicine practice they can expect when they begin incorporating the principles and practices of motivational interviewing. So let's go through these. First, motivational interviewing will focus on your patient's competencies and their strengths. It does this by emphasizing the individual's choice, and it supports and encourages them to make those choices. There's optimism that change can be achieved, while at the same time it is emphasized, and it's emphasized repeatedly, that responsibility for recovery rests squarely on your patient. Motivational interviewing is individualized, and it's patient-centered treatment. Positive treatment outcomes are best associated with programs that are flexible, and they focus on your individual patient needs. It's an individual treatment plan. Patients are given choices about treatment options. They're educated, and with your advice and support, they make choices. Motivational interviewing does not label patients, steering away from terms such as addicts or alcoholics. Motivational interviewing envisions partnerships, therapeutic partnerships for change. There's a partnership between you and your patient, agreeing on treatment goals, and working together to develop those strategies that are necessary to implement those goals. Motivational interviewing uses empathy. It is not a power-centered approach. It is not authoritative or paternalistic. Characteristics are found to increase a person's motivation, include good interpersonal skills, imbuing confidence in therapeutic change, and the capacity as a clinician to recognize where the patient is in the stages of change, and adapting therapeutic interventions that match that. And finally, motivational interviewing focuses on early interventions. Those early interventions range from such activities as educational programs, to brief interventions, to more comprehensive residential-type programs in the later stages of a substance use disorder. Motivational interviewing can adopt the principles of measurement-based care, and SAMHSA's Treatment Improvement Protocol 35 provides the instruments to help you move in that direction. Here on the slide, we have an instrument for measuring the readiness for change in a particular patient. The particular instrument that's illustrated on the slide is based on a four-question scale that was originally used with individuals that smoked. These questions were modified to inquire about drinking, and the responses are in a specific range for each question. A composite motivation score is calculated with a possible range from 0 to 10 based on simply adding up the sum of the patient responses. Illustrated on this slide is another instrument, the Readiness to Change Questionnaire. This particular instrument is organized in such a way that depending on your patient's responses, you can determine whether or not they are in the pre-contemplation, contemplation, or action stage of change. SAMHSA's Treatment Improvement Protocol number 35 has this instrument, and the scoring for it is included. The elements of effective motivational interventions are incorporated in the acronym FRAMES. Let's go through the acronym. The F stands for Feedback, the R, Responsibility, the A for Advice, the M for Menus, the E for Empathic, and the S for Self-Efficacy. So let's go through each in a little detail. The F for Feedback indicates that personal risk or impairment is given to the patient following the assessment of their substance use patterns. R stands for Responsibility. As we've mentioned before, responsibility for change is the patient's responsibility. The A stands for Advice about changing, reducing, or stopping the substance use. It's clearly given to the patient by the clinician, and it's done so in a non-judgmental fashion. The M stands for Menus of Self-Directed Change Options and the Alternatives that you provide your patient. The E stands for Empathic Counseling. Respect and understanding is the goal of motivational interviewing. And the S stands for Self-Efficacy, which is Optimism. It demonstrates to the patient that change is possible. As we've mentioned before, roughly 70% of individuals considering any change in their behavior are in the pre-contemplation or contemplation stage. In moving towards any decision, most people weigh the pros and cons, the costs and benefits of the action that they're considering. In behavioral change, these considerations are known as decision balancing, a process of evaluating the good and the bad aspects of substance use. This can help tilt the balance towards positive change through the use of some particular strategies. One way is by subtly accentuating the costs of the person's substance use. For example, among tobacco users, you might ask how much a pack of cigarettes costs, and then calculate the weekly or monthly expenditure in an offhand comment, and perhaps through further inquiry, figure out how this is affecting other expenditures in their life. Other approaches include lessening, when possible, the perceived value of substance use, emphasize what benefits may come about through minimizing substance use, discussing and discouraging obstacles to change. If you want to normalize ambivalence, it's a normal part of life. One always has to be thoughtful about change, and in very general terms, it's best to discuss the pros and cons of any particular choice the person makes. Your role as a clinician in helping tip the balance in a more positive direction is to help the patient be more thoughtful and reflective. There are questions that you can entertain that will move in that direction, and this slide has some examples. For example, it sounds like things can't stay the way they are now. You might ask your patient, what are you going to do now? Of the things I've mentioned here, which are the most important reasons for a change? How are you going to do it? What concerns do you have about change? Again, the purpose for the questions is to introduce a thoughtful, reflective discussion between you and your patient. Motivational interviewing emphasizes patient choice and responsibility. In motivational interviewing, it is not the clinician's responsibility to dictate a patient's choice. The clinician is a guide, providing information and encouragement. The clinician's task is to help your patient make choices that are in their best interest. Things that can emphasize personal choice should include comments that crop up frequently during your interview. Such comments as, it's up to you what to do about this. No one can decide this for you. No one can change your drug use but you. You must decide whether or not you want to go on drinking or change your behavior. Let's take a look at another video vignette. Based on what you've learned so far about the elements of motivational interviewing, analyze this video vignette. You know, Doc, I'm still not sure that I'm ready to quit yet and I'm just not sure I can do this now. Well, Mr. Edge, you know, we've talked about it at length at this visit and we've talked about other visits as well. You know, I just think you just need to make up your mind and just do it. Yeah, but, you know, I've tried in the past. I just can't do it no matter what I do. You know, I'm not really sure you tried that hard. And the last time, remember the last time you quit? Two days after your quit date, you got laid off for several months. That made it really difficult. This time will be different. And we have some new medication we can try. Yeah, I've tried all those medications and I've tried all the patches and all that stuff. And now that new medication, I heard some crazy stuff about that. Well, it's not as scary as what will happen to you if you keep smoking. Besides, I'll be monitoring you closely. Yeah, it's just not a good time for me right now. Hope is a powerful antidote to despair. Patients who have a serious problem and understand they have a serious problem are not likely to move towards positive change unless they can be convinced there is some hope of success. As such, self-efficacy is a critical piece of the puzzle in changing behavior. Self-efficacy embodies the notion that there can be a good outcome through your treatment plan. It's a source of optimism. Negative emotional states, depression for example, present a risk for reoccurrence of substance use disorders. And again, optimism and reasonable hope can be a tonic. Negative emotional states include anger, frustration, social pressures, such as seeing others drinking or using drugs. And there can be physical barriers, such as having headaches, feeling tired, being worried, withdrawal symptoms, and urges such as craving. Once you have determined your patient's stage of change, SAMHSA's Treatment Improvement Protocol Number 35 will provide you specific strategies to help your patient move along the continuum of change. If your patient is in the pre-contemplation stage, that means that they are not yet seriously considering or willing to make a decision. So how do you help this patient make positive change? Perhaps first and foremost is establishing a trusting relationship. You also want to provide education about the risks of substance use. You just completed a comprehensive assessment of the patient and now you're ready to move along. You just completed a comprehensive assessment of the patient and now you provide those personalized findings to the patient and you can explain them in some detail. You can explore the pros and cons of substance use. Remember, the patient is not yet quite at the ambivalent phase. You always want to end the interview by leaving the door open to further discussion of the topic. It's not being dismissed. It will be revisited at a later time. But for now, establishing a trusting relationship, providing information that led to your diagnosis, and discussing the risks of substance use are important milestones. When you look at this video, see if you can determine what techniques the clinician is using. Is it effective? Hi Amber, thanks for sitting down with me. As your pharmacist, I noticed that you're on your third prescription of antibiotics and I just wanted to sit down and ask how you felt about that. I'm annoyed. I'm sick of being sick. Okay. Do you mind if I ask, are you a smoker? Yeah, why? Well, a lot of the time smokers are actually sick more often and for a longer period of time. And I'm wondering if you'd actually, if it'd be okay if I ask you a little bit about your smoking. You're not going to tell me to quit, are you? No, I wouldn't tell you what to do. You know, I'm just, I'm not ready to quit right now. I feel like I have a lot of stress in my life. I've got a lot of stress at work. I feel like I'm sort of getting it from every place and, you know, I'm getting it from my kids too. So you have a lot of stress in your life and it's really bothering your kids that you're smoking. What are some other negative consequences of you smoking? Well, I mean, I know that it affects my health. It stinks. It costs a lot of money. And I do think a lot about, you know, I don't want my kids to smoke and I hope that this isn't a way of me encouraging them. So if you were to think about quitting right now, do you think you'd be able to do it? Honestly, I'm not sure. I think it would be too stressful for me at this point. So you have a lot of stress to deal with. Yeah. Okay. So right now really doesn't sound like a very good time for you to quit. I don't. I don't think it's a good time. Just with work and just everything I'm dealing with at home, I just don't think I can handle that stress on top of this stress that I'm already dealing with. Okay. Well, right now it's not a good time for you to quit, and I totally understand. It's definitely your choice and whenever you feel, if you ever feel that it's appropriate and that you want to do that. I have some information here for you to take home if you want, just some reading material about quitting and some quitting tips and the health benefits of quitting. And so you can take these home with you and read them if you want. And whenever you are ready or if you ever have any more questions, feel free to come back and talk to me about that. Is that okay? Thank you. Yes. Okay. Thank you. In this slide we have suggestions on how to address an individual that is in the contemplation phase. As you recall, when an individual is in the contemplation stage of change, they're considering that their behavior may be a problem, but they're not certain. Strategies to help move the patient along the continuum of change include, perhaps first and foremost, you want to normalize ambivalence. Making difficult decisions can be stressful. It's normal, but that doesn't mean you avoid it. Help your patient tip the decisional balance toward change by exploring the pros and cons of substance use as they see it. Examine the individual's personal values in relation to change. And again, throughout this discussion, you want to emphasize individual choice, responsibility is theirs, and you want to be optimistic. You want to elicit self-motivational statements that indicate the individual is moving towards embracing change. And you want to summarize your discussion with self-motivational statements that the individual has produced during your session. The action stage is the opportunity for the patient and clinician to develop a treatment plan. In developing the treatment plan, the clinician offers a menu of change options. You want to lower barriers to any perceived action. Enlisting social support is another important piece of this. And you want to continue to educate your patient about the various treatment options. Again, at the end of the day, it's their choice. The menu of options that you might consider matching with the patient's substance use disorder might include self-help groups. It could involve enrolling in an intensive outpatient treatment program. It could include residential treatment. And it would also include who else will be involved in the treatment plan. Family, fellowship meetings, or even potentially members of the workforce. Good afternoon, Mr. Shields. My name is Ellen. I'm your nurse today. How are you doing? Hi, Ellen. I'm Dave. I'd like to take a few minutes to talk to you about your tobacco use. Is this a good time? Sure. I was wondering if anybody was going to bring it up. Can you tell me a little bit more about the tobacco products you've used in the last year? Well, I smoke cigarettes. I smoke about a pack a day. I've tried to quit before, but it never seems to last for more than a few days. It's really difficult. Even after having a heart attack, all I can think about is going out for a cigarette. Since I can't smoke while I'm here anyway, I wouldn't mind quitting a try. Well, it's really wonderful to hear that you're willing to give it a try. I mean, most individuals, it takes several tries before they are even successful at quitting. As you probably know already, the hospital grounds are smoke-free, not just in the hospital, but the grounds around the hospital. And with your health issues and whatnot, quitting is the most important thing you can do for your health right now. So what do I do when I want to have a smoke? Well, we'd like to make quitting a little easy for you while you're here in hospital. And we can start off by giving you some nicotine replacement therapies to reduce your cravings and we'll also monitor your symptoms during your stay to make sure that it's working for you. So I have a few things here for you. It's some information on some tips and ideas on helping you successfully quit. Okay. And after I go home, what do I do? If you'd like, closer to your discharge, I would fax in a referral to a program called Alberta Quits. They offer tobacco cessation counselors that can call you and follow up with you to see how you're doing or offer you any other tips or ideas for helping you quit. That's going to help me a lot. Even if I don't use the counseling, it's reassuring to know that somebody's going to call and that help is available if I need it. So thank you very much. I'm just going to go out and get your nicotine replacement ready. Thank you. See you. Some patients might find a change plan worksheet helpful in organizing their thinking. A change plan worksheet is illustrated on this particular slide. You would ask your patient to focus on the positive changes they want to make, such as wanting to increase something like more time spent with their family, improve their job performance, or decreasing a certain behavior. It's also important to ask the patient to indicate on the worksheet how they're going to manage obstacles that may arise and provide setbacks to their plan. No treatment plan would be complete without a discussion of relapse triggers. Relapse triggers are behavioral cues that are associated with drug and alcohol use. And when the individual encounters these, it increases substantially the likelihood that they will reengage their previous risky behavior. For example, you may have a patient that uses cocaine, and when she goes out for an evening with a particular group of friends, they may not be using that drug, but they may be drinking alcohol. This particular patient is particularly vulnerable because of the relationship behaviorally between the use of alcohol and cocaine. The two are linked in her mind behaviorally. Coping strategies to consider that might mitigate the risk include such things as going out with a different set of friends, go along with this group only for activities that do not involve the use of alcohol, leave the group as soon as it appears likely that drinking may begin, and ask all of her friends to help her by not using alcohol when she is around them, indicating to them that she is in the early phases of recovery. On behalf of the American Osteopathic Academy of Addiction Medicine, let me thank you for participating in the Essentials of Addiction Medicine Introduction to Motivational Interviewing.

motivational interviewing

addiction medicine

patient-focused psychotherapy

substance use disorders

behavioral change

stages of change

evidence-based approach

communication strategies

trusting relationship