Hello, welcome to PCSS MAT training. This presentation is on principles of Motivational Interviewing useful for primary care physicians. My name is Joji Suzuki. I'm the director for the Division of Addiction Psychiatry at Brigham and Women's Hospital, Assistant Professor of Psychiatry at Harvard Medical School, and also a member of Motivational Interviewing Network of Trainers. I have no financial relationships to disclose. And the target audience for this presentation is that the overarching goal of this PCSS-MAT is to make available the most effective medication-assisted treatments to serve patients in a variety of settings, including primary care, psychiatric care, and pain management settings. Educational objectives for this presentation are at the conclusion of this activity participants should be able to describe the spirit of motivational interviewing and its four processes, utilize patient-centered MI skills to help elicit and strengthen the internal motivation for change, and summarize how to plan for change in a MI-consistent fashion. So let's jump right in. When we think about health care settings, we as clinicians actually frequently recommend behavior change to our patients. In fact, I would argue that it's pretty unusual for us to encounter a patient and say that they should change nothing. Typically, we are recommending taking a medication, stopping certain behaviors, like substance use or eating junk food, for example, or doing things that they're not doing, such as exercise or going to treatment, etc. However, I think every clinician knows that these recommendations aren't necessarily taken and completed by the patient. In fact, these conversations about behavior change often turn into sort of arguments. And what I mean by that, it's not necessarily a shouting method between the physician and the patient, but we make recommendations for change, for example, we may ask a patient to stop smoking. And then, not all patients, but some patients may respond to that by saying something like, yes I know but, and give you an excuse. And what often happens after this is that the clinician will further argue for change, coming up with some reason for why stopping smoking is important, coming up with other reasons, etc. And then the patient will further entrench in their position for why they do not want to change. So the basic dynamic that gets repeated is that we argue for change, and a patient argues yes, but no. Now, when this happens, the question for you is, how does that make you feel. When you are making recommendations for change and the patient is arguing back, it's a confusing situation because we became healthcare providers because we want to help patients. So we're offering help, and the patient is rejecting our help and when this happens, typically what happens is, we're made to feel like we're not being helpful. We get frustrated, we feel powerless, we feel like we're wasting our time, makes us feel incompetent, and basically, we don't really enjoy that our recommendations are being rejected or the patients are arguing back. So it turns out that this is a very common outcome. And this is true whether you are early in your career as a medical student, a resident, a fellow, or whether you've been practicing for many decades, a nurse, social worker, a dietician. This is actually a fairly universal experience among clinicians. Now, what Motivational Interviewing would be able to help you with these encounters is that hopefully, by learning motivational interviewing, you would feel less frustrated having these conversations. Ultimately, we can't eliminate the frustrations because these conversations are never going to go perfectly smoothly. But with motivational interviewing, I can tell, say, from my personal experience and many others, they can be far less frustrating. But just as important than being less frustrated, I think it's important that we are even more effective on helping our patients change. And I think if you can achieve these two goals, I think that's a pretty good thing. Again, if you learn motivation really well, these two outcomes are actually very much achievable. So what is motivational interviewing? And really it boils down to these things. Motivational interviewing is a guiding style of communication. It is not simply doing what patients want to do. We actually are trying to balance what we think the patient should do, but also doing it in a way that really minimizes a patient rejecting our recommendations. And how you do that is really pay a lot of attention to the language of change, I will be speaking quite a bit about that, and then evoking from the patient their own reasons for change. If you're able to embody these ideas into your practice, then you're probably practicing some type of motivational interview. It's also important to understand what Motivational Interviewing is not. Motivational Interviewing is not psychotherapy. It can be done as a type of psychotherapy. However, again, it's really a style of communication. Therefore, Motivational Interviewing can be done in three minutes, if that's all the time you have. You can spend an entire hour using Motivational Interviewing, but there's no requirement to do so. There's no set number of sessions that you must do. You don't have to be a mental health clinician at all. It is again, a style of communication. It's also important to distinguish Motivational Interviewing from stages of change model. I don't want to get into too much detail with this, but just suffice to say, stages of change model is a great theory and some of the nomenclature we use there is useful in talking about behavior change. But ultimately, as a clinical method of behavior change, there's very little empirical support for stages of change model. Motivational Interviewing, on the other hand, is extremely based on empirical evidence. Motivational Interviewing is also not doing a decisional balance, or sometimes called the pros and cons. It may be part of a Motivational Interviewing conversation, but in and of itself, decisional balance has no impact on behavior change or motivation, unless it's done in a very strategic fashion, and I'm hoping that Motivational Interviewing, by learning that you'll see how the two are different. It's also not for every patient in every situation. There are times and motivation timing is not appropriate. It's one tool among many different tools. So Motivational Interviewing, unfortunately will not replace everything and be effective for every patient in every situation. I think what's most frustrating for me as a trainer is that it does take a considerable amount of practice and feedback to get better at Motivational Interviewing. It does take a lot of practice and it's not easy to attain competence. However, that said, it is a very vulnerable skill. [COUGH] This slide is trying to show a study that was done by Lundahl and Burke, which was a meta-analysis of the four meta-analyses that have been already completed on Motivational Interviewing for a variety of target behaviors, from substance use, diet and exercise, treatment adherence, etc. And if you combine the four meta-analyses overall, Motivational Interviewing comes out definitely better than weak competitors, meaning no treatment or treatment as usual and, and probably equally effective as other effective therapies such as CBT. For example. And so the effect sizes aren't huge, but they're not tiny either. They're moderate effect sizes for, again, a variety of target behaviors. One of the unifying themes in motivational interviewing is this idea called spirit of motivational interviewing. If you're truly able to embody these ideas in your practice, you probably are practicing motivational interviewing and really just going to quickly acceptance. Embedded within that are two ideas. One is respect for patient autonomy and the other is accurate empathy. Respect for autonomy is probably one the most critical things in motivational interviewing and I'll be seeing more about that as we go along. Accurate empathy also is a sort of the flip side of respect for autonomy and being able to embody that is actually very critical. Partnership is implying that we have to partner with our patients not as sort of an expert and a novice, but partnering as equal experts. When it comes to managing chronic disease and other unhealthy behaviors, unlike managing acute issues and emergent issues where we often do adopt the role of an expert and adopt a more paternalistic approach. When it comes to managing chronic diseases and unhealthy behaviors, it is far more effective to adopt a more equal sort of power dynamic. Because we are experts about the content, the treatment, the diagnoses, the dosages, the side effects, that treatment guidelines, etc. But our patients are also experts about how to successfully implement the recommendations into their own lives. The recommended plan is never implemented by the physician or the clinician, it's implemented by the patient him or herself. And therefore, they have to understand how to be experts in understanding the recommendation, who to get the recommendation from and how to successfully implement that plan into their daily lives. Evocation is something that I alluded to earlier, in that, we have to evoke from the patient his or her own reasons for change and this is another critical point in motivational interviewing. It really doesn't matter what we think is the right reasons for change, if it doesn't apply to the patient him or herself, it has to come from within the patient. And finally, compassion simply implies that we should be recommending these changes for the benefit of the patient. When it comes to actually doing the interview and thinking about how the interview may occur over many visits over weeks, months and years, these four processes are very helpful to be thinking about. And they go in in sequential order, it starts with engaging, focusing, evoking, then planning. Before processes, the first and the last are almost always done by every clinician. Every clinician knows to sort of talk to the patient, get a little bit of history, and then based on that information we come up with some kind of formulation and recommended plan. So for example, as a psychiatrist, I might recommend to a patient after a period of time collecting to data. Tell a patient, I think you have depression, you should take Prozac 20 milligrams once a day and go to therapy and I'll see you next week. Now, if the patient simply did exactly what you recommended, we wouldn't be here talking about motivational interviewing. As we know, many patients do not adhere to those recommendations. Therefore, in motivational interviewing, we recommend you do at least two other things before you come up with a plan or recommend a plan. And that focus a conversation on the particular target behavior, and then utilize whatever time you have to evoke and strengthen the patient's own reasons for change. Now, as I said earlier, these four processes may be completed in one single visit. But in reality, you would iteratively repeat this over many visits. Because unfortunately, most behaviors will not change after one conversation, it often requires many encounters over many years. That said, studies do show that even one encounter of less than half hour, sometimes as brief as five minutes to ten minutes, those actually have an impact of the behavior itself. They may not sufficiently fully quit their smoking, or change their diet, or start exercising, but it does have some impact. And that's been shown repeatedly in many studies. So again, the four processes will be completed in one encounter and it could take maybe a couple of minutes. And this would be repeated potentially over many encounters over months and years potentially. So let's start with the engaging process and really, it's hard to sort of understate the importance of engaging. This is actually a new element in the current iteration of motivational interviewing. In the prior iteration, they didn't necessarily specify the importance of engaging. And what ended up happening is that many clinicians saw motivational interviewing as a collection of certain things, tools that you kind of throw at the patient and hope that it would work. But that led to motivational interviewing being too sort of algorithmic, and without enough attention being paid to the importance of the relationship with the patient. [COUGH] Some of the ways in which the conversation about behaviors in can be started, are pointed out here. For example, asking permission from the patient if it's okay to talk about a particular behavior is a very effective way to open it up. So would it be okay if you spend a few minutes talking about your opioid use is akin to knocking on a door. And if a patient lets you in, by definition, they're making the choice to speak about it. If you simply barge in without knocking at the door, there's that there's a higher likelihood that the patient will reject you, because you weren't let in by them. [COUGH] And then this just really start with sort of a broad [COUGH] question like, tell me a little bit about how your heroin use fits into your life? Now, another would be to start by asking what is it that they enjoy about this particular unhealthy behavior such as asking, what do you like about heroin? And only then moving on to questions about what are some of the not so good things about heroin. [COUGH] All these strategies are aimed at, again, furthering the engagement with a patient without first coming across as being challenging. Or criticizing the particular behavior, because many patients actually expect that. They're expecting that the healthcare provider would immediately go into sort of criticizing the unhealthy behavior and asking you to change it. So preventing doing that immediately is part of engaging process, it's a trust building process. And sometimes we call that the writing reflex when the clinician wants to immediately correct and fix what's wrong with the patient. So maybe paradoxically not doing that first helps to build trust that you're not actually willing to listen and learn some patient why this particular behavior, why they're still engaging in that behavior. One of the things we [COUGH] recommend is throughout the interview process using motivational interviewing is to utilize [COUGH] the OARS skills. And the OARS stands for Open ended questions, Affirmations, Reflections and Summaries? The open ended question is fairly self-explanatory if I won't describe that. Affirmations, reflections and summaries are all types of reflective listening [COUGH]. And it turns out reflective listening is probably the most critical skill that we use in motivational interview. And it's particularly effective during the engagement stage. In fact, it's effective throughout the process of motivational interviewing, but it's very effective, because It's an excellent way to demonstrate accurate empathy. And reflective listening, again, without doing that, it's actually not as easy to demonstrate empathy. If you're able to do reflective listening there, you're actually demonstrating empathy, and that goes a long way, especially early in the encounter in building a trust. When I was a medical student, I did learn empathic statements, and these are some examples of them. And the problem with that is that they can often sort of be rejected by the patient because even though you may be empathic, these statements do not actually convey any understanding of the patient. Instead, reflective listening works this way. The speaker thinks of something to say, they actually say it, you hear it, you're interpreting what they meant to say, and then you're reflecting it back. And there are two basic types of reflective statements you can use, simple or complex. Simple reflections are reflecting what the speaker said. So what appears in the bubble there, you're kind of reflecting what you hear as you're hearing it, without really interpreting it much. But complex reflections, on the other hand, actually do try to understand what the speaker is actually trying to convey and communicate. So it goes much deeper than simply what was said. So let's see some examples. With simple reflection, as I said, we're trying to stay very close to what was said. And if a patient says something like, I need to stop using cocaine, you might reflect that by saying, you want to stop using cocaine. In this example, I actually demonstrate this, that's actually a picture of me in the slide, I actually demonstrated that I heard what she said. I didn't say to her, I heard you, my words actually conveyed that I actually heard her. Also please note that the end of the sentence, the statement, is a period and not a question mark. Even though this may seem subtle, we recommend that the reflective statements are done as statements and not questions. So it shouldn't be, you want to stop using cocaine, where the intonation goes up at the end. It's a subtle difference, but questions tend to demand an answer. And reflective statements are much more flexible and patients are able to flexibly respond to it without feeling compelled to answer a question. So we actually recommend keeping it a statement. Let's see another example. Patient says, my drinking is not a problem, you reflect back, your drinking is not a problem. Again, this is simply parroting, but we're conveying that we understood. Now, of course, if you simply repeated back everything you heard, it gets pretty irritating and annoying very quickly. So instead of doing that, what we recommend, and what the MI teaching says, is that we should try to complexify the reflections. In fact, a competent motivational interviewing clinician will predominantly use complex reflections and simple reflections are used less frequently. And the way we define complex reflections that you should be adding substantial meaning to the reflection so that you're not just reflecting what you heard. But you're making some interpretation or hypothesis about what the person's trying to convey. So if a patient says, I want to stop drinking, an example of a complex reflection might be, the recent DUI was a wake-up call. Now, that's not what she said, but you're trying to understand what she's trying to convey. Now, what's interesting about complex reflections is that when you first see this, it seems very presumptuous and that we're just throwing words into our patient's mouth. It may feel that way. However, as long as you're doing this in an authentic way with a genuine curiosity about what the patient's trying to say, and that you're willing to be wrong. If your reflection is indeed correct or near the truth, most patients will respond to a reflection with some affirmation saying, yeah, that's true, and we'll keep talking about it. In fact, a complex reflection will have a patient talking more about that particular statement, so it furthers the conversation. On the other hand, if you're wrong, if your reflection is wrong and your hypothesis is absolutely off the mark. What's really interesting is that many patients will respond to that by saying, well, that's not what I meant, doctor, but what I actually meant to say was, and will often correct you. So either way, whether you're right or wrong, it has a tendency to deepen the understanding of the patient and further the conversation. Now, of course, if you give a complex reflection that is off the mark ten times in a row, that's actually not good at all because you're actually demonstrating you're not understanding. But as long as you're actually listening to the patient, trying to understand, and trying to convey that to the patient, the patient will experience that as somebody really trying to make an effort to understand. And that's exactly the reason why or part of the reason why reflective listening is very effective in deepening empathy and rapport. Let's see another example of complex reflection. I think I need help, I want to stop using heroin, and a complex reflection might be something like, you're afraid what would happen if you keep using, and you realize you can't do this on your own. So again, this is a reflective statement of what the patient said, making hypothesis about what she meant, here we're adding you're afraid, so adding some affect. And you realize you can't do this on your own is sort of affirming this realization that the patient may have had. We don't really know for sure, but we're making assumptions. And we'll see how the patient responds to that. So again, reflective listening is a very effective way in conveying empathy, and it's particularly effective during the engagement phase for another reason, I said earlier, avoiding the righting reflex. So instead of jumping to giving recommendations or correcting things, we're kind of sticking to understanding the patients first. And again, that really is an important part of motivational interviewing. Let's see another example, I shouldn't be snorting percocets anymore. On the one hand the pills make you feel normal, and on the other hand you realize you could overdose any day. This is a special type of complex reflection called double-sided reflection, where you first are actually reflecting the ambivalence the patient has. First you're reflecting kind of the reasons why she might like to use percocets. And then you alternate that on the second half of the reflection with a reason why she might want to stop. It's called a double-sided reflection, and it's a particular type of complex reflection. So that's the engagement phase, and we're going to move on to the focusing phase. But I just want to point out that one thing we try to recommend is maybe consider spending 20% of your time, whatever encounter you have, whether it's a 10 minute encounter, 20 minute encounter. To consider using up to 20% of the time simply focus on engaging with the patients, conveying empathy, demonstrating you can listen, and avoiding the righting reflex. Then moving on to focusing. This is an idea that patients come to us with their own agenda about what they want to accomplish in that encounter, which may be completely different from what you as a clinician want to accomplish. And so it definitely makes sense at least to spend some time, if needed, to make sure that the agendas are aligned. Now, sometimes the focus is very clear. If you are a smoking cessation counselor at a smoking cessation visit with a smoker coming to the visit, the topic of the conversation may be extremely clear. Other times, there may be several options, and this is actually very, very frequent for most clinicians. There are multiple issues to discuss, but they need to be prioritized, and an agenda needs to be created. Sometimes actually no clear path at all. This may be common in supportive psychotherapy where, on the first visit, really, it's not clear what the patient really wants. And then the encounters will be used to kind of decide on what path to take. So if there is a clear path, you may not spend any time at all focusing. If there's no clear path, that may be your entire focus of that encounter, is to decide what the focus is. But for most most situations, you're trying to negotiate what the topic should be among several options. For the purpose of this training itself, we don't have time to get into too much of the techniques of it. But it's simply to suggest that it may be good to explicitly ask the patient, what is the most important thing for us to discuss today? And if there's a discrepancy in what you want and what the patient wants to talk about, maybe it's helpful to simply say, would it be okay that we talk about this particular topic? Again, going back to the asking permission. Now let's let's move on to evoking phase, and this is really at the sort of the heart of motivational interviewing. I said earlier that our goal here in motivational interviewing is to evoke from the patient his or her own reasons for change. And this is probably, again, the most important part of motivational interviewing. And the way I like to conceptualize this is to imagine a hill, going upwards, and when the patients come to us, they're at the bottom of the hill. And the height of the patient here, in this sort of slide, represents the level of motivation. If the person at the bottom of the hill has low motivation for that particular target behavior, and our goal is to increase it so that this person is higher up on the hill, and their motivation is stronger as well. Our assumption is that, as we increase a patient's motivation for change, the chance that the change will occur actually goes up. And so part of what we're trying to do in motivational interviewing is to create a discrepancy between where they are currently, down here, and where they would like to be, up there. And what it would take to actually accomplish that. Now, like I said earlier, there's no assumption or fantasy that a five-minute, ten-minute encounter will successfully raise a person's motivation from the bottom to the top. That's usually unlikely, so it's very important to keep that in mind, that this may occur over many, many visits, over many months and years. The other part of the problem is that when you're at the bottom of the hill, you really don't know how high this mountain goes. You may be pretty close to the top already, or you may be way at the bottom. And actually, there's no real way to know beforehand how far away they need to go for the change to occur. And actually, this is an important point because in many of the patient that we work with, there's absolutely no guarantee that just because you do this, the patient will change. In fact, in my own clinical practice, there have been countless patients who have unfortunately died. Even though their diabetes were never fully controlled, they were still obese, they were still smoking and using substances. But that doesn't change the fact that our task remains the same. Our task during motivational interviewing is to do what we can to strengthen the person's motivation so that this goes higher and higher and higher, so that the change becomes possible. And so if we're thinking about increasing somebody's motivation, how do we actually do that? And in motivational interviewing, we try to conceptualize the difference between external motivation and internal motivation. Clinicians tend to over-rely on externally driven motivation, for example, the clinician telling the patient what to do and how to change. We're the motivator, we're arguing for change. We may sometimes use logic and a rationale, or we try to be persuasive, and even times that we're being coercive. If the situation is emergent and acute, for example, a patient is bleeding profusely from a major, major injury, that is the time for us to be actually be much more paternalistic and be directive. That´s actually demanded. In fact, we´re obligated to do so. As a psychiatrist, if I encounter a suicidal patient, I actually want to do coercive treatment. I will force involuntary treatment. Even if the patient wants to go home, I will actually implement coercive strategies. However, when it comes to, again, unhealthy behaviors and chronic disease management, such approaches using coercive strategies aren't as effective. We need to, instead, focus on increasing somebody's internal desire to change, and I think that's somewhat obvious. If a smoker wants to quit smoking, we could tell the patient to quit, but ultimately, the quit attempt will only be successful if the patient, him or herself, wants that themselves. The problem with internal motivation is that we can't directly see it or measure it, so we actually use another measure, and that's ambivalence. Because, it turns out, most patients are ambivalent about unhealthy behaviors, and what we mean by that is that patients feel two ways about it. They want to change, and they don't want to change, simultaneously. Both ideas are within the same patient at the same time. It turns out this is actually very normal, quite healthy, and it is not pathological. Most decisions all of us make, we're never 100% sure, whether to take a certain job, or who to marry, where to live, which house to buy, whether to have children or not, etc. These major decisions in life, none of us are usually 100% sure [COUGH]. In fact, that's considered healthy because we can modify our decisions based on further information. And it's turned out to be largely true, [COUGH] well, for patients engaging in unhealthy behaviors. The majority of smokers [COUGH] are actually ambivalent about their behavior. Part of them wants to continue, and part of them wants to stop, and that's actually very normal. Now, the ratio of the wanting to change versus not wanting to change may not be 50/50, it may be 1 to 99 [COUGH] or 0.01 to 99.99. But the point is there's some ambivalence. And this side of the ambivalence, the side that the patient wants to change, we call change talk, and the other side of the ambivalence we call sustain talk. And this is probably one of the most important contributions that motivational interviewing has had to the behavior change field, to try to sort of name these sides of the ambivalence and do something about it. So change talk represents the side of the patient that wants to change, and sustain talk is the other side. What we're advocating in motivational interviewing is that if we argue for change, if the clinician is the one telling the patient that they need to change, there's a tendency for patients to go to the other side of the ambivalence. And I think this may be a experience that all of us can relate to. None of us like to be forced into doing things, even if we agree with it. And this is what I meant earlier, and the spirit of motivational interviewing, about acceptance. I said that embedded within that are two ideas, respect for autonomy, and accurate empathy. And here's what we mean by the respect for autonomy. If we Disrespect somebody's autonomy. There's a tendency for them to reject our efforts to change them. And they get entrenched in the side of the ambivalence that doesn't want to change. So when I'm forced to do something that even if I agree with, my initial sort of impulse is to want to find a way to reject it or or argue with it, because I'm being forced into something. Even if I agree with it, if I disagree with it certainly makes it even easier for me to push back against it. So in motivational interviewing instead of the clinician arguing for change, we ask the questions to evoke from the patients to change talk. We want patients to argue for change themselves. So the clinician should try to avoid arguing for change, and then we should evoke from the patient their own reasons for wanting to change. Because it turns out clinicians, oftentimes focus way too much time on addressing sustain talk. We shared the excuses that patient gives us for why did they want to change and we assume that if we address that, change will occur. Now, I think that's a incorrect assumption. A common reason for an obese patient to give to a clinician for why they didn't exercise is the lack of time. Now if he added magically one extra hour to all our obese patients, do we think the change will occur and everybody will lose weight? Highly unlikely because it's not just about the barriers. There's certainly real, but if there isn't sufficient motivation to change, then change is not going to be inevitable. However, if we focus instead or focus as much attention on it and increasing somebody's motivation to change, then even despite having the barriers, change may be possible. So ultimately, both sides do need to be addressed but clinician disproportionately spend way too much time on arguing and addressing barriers in a sustain talk without paying enough attention to strengthening and invoking change talk. So what is change talk? Here are some examples, and we just use the mnemonic called DARN-CAT. Desire, ability, reason, need, commitment, activating in steps taken. So this is language that indicates movement towards change. So for example, I want to stop using heroin. That's a pretty strong, pretty obvious change talk. I'd like to cut back on how much I use. That would be another type of change talk. I could try treatment if it fit my schedule, I know I can cut back on how much junk food I eat or I want to change because I don't want to die of an overdose. So all these are statements that indicate movement towards change. And what we think in motivational interviewing is that the statements represent the internal motivation of the patient. But it's important to distinguish the language itself from what's generating a statement. Because I can't simply say to a patient repeat after me, I want to stop using heroin. And say that a 100 times and you'll be motivated, and we know that's not true. So change talk is really language that's evoked or comes out from within the patient because something within the patient is generating that. And we think it's the patient's internal motivation to change that generates this language, of the desire, ability, reason, need. And these first four, sometimes called preparatory language. Meaning, this is still excellent to get this type of change talk, but the last three maybe a little bit more stronger in terms of our commitment to change. But ultimately, evoking and strengthening any of this is actually a good clinical strategy in motivational interviewing. And just to point out, sustain talk is the exact same language in the opposite direction. So, is there any evidence to support this? In this particular study, examined a previous study called project match which was one of the largest psychotherapy trials for alcohol dependence. And patients received several months of psychotherapy and their drinking outcomes are followed for a year or more afterwards. And what researchers did, was they went back to the study and listened to the conversation that the therapists were having with the patients. And counted the frequency of change talk and sustain talk that emerged during the encounter. And what they wanted to do was see if the frequency of change talk and sustain talk correlated with drinking outcomes one year later. So, pretty sustained behavior change, not immediate change but sustained change one year later. What they discovered is that, the frequency of change talk actually correlated with improvement in drinking outcomes one year later, some fewer drinks for drinking days, they're more likely to be absent. But the exact opposite was true about sustain talk. The frequency of sustain talk actually predicted the worsening of their drinking behaviors one year later. They were drinking days and less likely to be absent. For the first part of the model of the motivation we were trying to build is this. More change talk is actually good, it predicts later behavior change, and then more sustain talk is actually not so good, because it does not predict behavior change later. So what people say, seems to matter and is predictive of what's going to happen later. Now that said, if this were the only part of motivational interviewing, behavior change is almost entirely about readiness to change. Patients who are ready to change will come to you with more change talk. Those who are not will give you more sustain talk. And that sort of raises the question, so what is our role in this? And it turned out there's a lot we can do. So, the same researchers looked at a different aspect of the conversation and instead of looking at frequency of change talk and sustain talk, now they looked at the therapists behavior. Encoded whether the therapist adhered to the principles of motivational being or not. The spirit of MI, the accurate empathy and the respect for autonomy and partnership, and etc., and very concrete behaviors. For example, I kind of alluded to earlier but asking permission before raising a topic is actually very important. And it turns out, asking permission before giving any kind of advice is a very important recommendation in motivation because it respects the person's autonomy to reject that advice before it's even delivered. So if a therapist asked for permission before giving any advice, it will count as MI consistent behavior. If not, it will count as a motivation of doing inconsistent behavior. And what they did in the study is they want to look at what the patient said immediately after that behavior, whether it was change talk or sustain talk. And what the study found is that after motivational interviewing consistent behaviors, the likelihood of change talk appearing went up. However, sustain talks early emerged after such behaviors. In contrast after motivational interviewing inconsistent behaviors In this particular study, change talk never appeared, but the likelihood of sustain talk appearing increased. And so the model looks like this. How we behave, whether it's consistent with the MI principles or not, has an influence on what people say, which we think is a reflection of the person's internal motivation. And what people say seems to predict what happens later. So how we behave has an influence on the person's motivation, which seems to impact what they say, which seems to predict what happens later. And the critical thing to point out here is that this part of the model is what we have control over. We have control over what we say, how we behave, how we respond to our patient, and how we can influence their motivation in that particular moment. However, we don't have control over this part of the equation. Because as soon as the patient leaves our offices and tries to implement our recommendations, it is actually up to them. And this part is actually very important. If a smoker successfully implements their quit attempt, it is actually the patient who has to accomplish that. So the patient gets probably most of the credit for actually implementing the recommendations successfully. Because it's only because they implemented it that the change occurred. So even though, as clinicians, we do like to take credit for positive outcomes, in reality, when it comes to chronic behaviors, chronic diseases, and especially substance use disorders, we only get partial credit. The patient, who actually implemented the strategy, the recommendations, etc., who had to suffer through that attempt and that behavior change, actually gets most of the credit. So there's a saying in motivational interviewing, we should take ownership and responsibility for the intervention, but not the outcomes. Because ultimately, that is up to the patient, and patients are actually allowed to make poor decisions. They're permitted to do so. We hope that they don't. But I think, as clinicians, we often confuse the outcomes as being our responsibility. When it comes to chronic diseases, it's not. If you're a surgeon, I think the outcomes are far more related to the clinicians and the healthcare providers. But again, when it comes to managing obesity, hypertension, substance use, etc, I think we should be mindful and remember that our control goes so far. And ultimately, patients are able to decide the final outcome. So we should do whatever it takes to maximize the chances that it'll occur, and focus on implementing the best intervention possible. So how do we actually increase somebody's motivation? We talked about evoking change talk, so how do we actually do that? So here's one quick example. This aligns with the first four of the change talk, the DARN cat that we saw earlier, DARN, desire, ability, reason, need, and questions that are aligned with that. What do you want to change is a desire question. We're asking why they would want to change, or what is it that they want to change? And the answer to that question is change talk. The patient might answer, I'm thinking about cutting back on how much Percocets I use, or how much heroin I use, or I think I want to maybe think about treatment, etc. The answer, again, to the question, what do you want to change, is change talk. When you go to the next one, if you were to stop using heroin, how would you be successful? The answer to that question is change talk. Well, if I were to stop, I guess I'd have to go to treatment and take a medication, or go to counseling. Whatever they say, the answer to this question is change talk. The next question, what are the three most important reasons for you to stop using heroin? Again, the answer to this question will be change talk. Now, what I want folks to recognize is that we established earlier that patients are usually almost always ambivalent. What that means is they feel two ways about it. They want to change, but they don't want to change at the same time. So a patient might say, yeah, I'm thinking about cutting back on how much drugs I use, but I don't want treatment, I don't want to change. Even if the patient now tells you they don't want to change, it doesn't stop you from actually trying to evoke and strengthen change talk. So for example, you could still say something like, you might reflect that back by first saying, I hear you loud and clear. Right now it's not your priority to stop using drugs, and nobody's going to force you to do that. I hear that loud and clear. And then you can actually still go on and evoke change talk by asking, but It sounds like there's a part of you that might be interested in treatment. And so if you were to stop using heroin, how would you be successful? Or you could be saying, I hear you loud and clear, you don't want to stop using drugs, okay. But let me ask you, what are the three most important reasons for you to stop using heroin, if that's something you decide to do? So even if the patient is saying they don't want to change, our assumption is that patients are ambivalent. And we can still work to evoke change talk, and strengthen it, while still respecting the decision to not change. And in a way, that's the paradox of behavior change. If we're able to acknowledge and respect their ability to refuse to change, then paradoxically, they're actually more willing to listen, or feel safe in telling their honest ambivalence about that particular behavior. For the final question on the taste of MI questions is a scaling question. There are many scaling questions in motivational interviewing, and here's one example of it. On a scale of 1 to 10, 10 being completely important, 1 being not at all important, how important is it for you to stop using heroin? And you typically get an answer between 3 and 7. But it's not the answer that's really important, it's the follow-up question that's critical here. Why did you answer 5, and not a lower number? Because the answer to that follow-up question is change talk. So I hope you get a sense that these are some quick examples on how you might evoke change talk without arguing for change yourself. Let's see a few more examples. Another easy way to evoke change talk is looking ahead. How do you want your life to be different in the future? So how would you like your life to be different in a year from now? Or in the coming year, what are your top priorities for your health? Again, the answer to this question is typically going to be change talk. Another really easy way to evoke change talk is looking back. Prior successes, attempts, or efforts are always very easy change talk to evoke. What made you decide to start going to the AA meetings last year? What supports were most important? It looks like you were in treatment for over a year back in 2014. How were you so successful? Again, looking back at prior efforts and prior successes is an easy way to evoke change talk. Now, patients generally don't say just one thing and wait for you to respond or just say one change talk and wait for you to respond. Patients often respond and say many things. And here's an example of what a patient might say. I don't drink any more than my friends. Sure I sometimes feel a little foggy the next day, but its no big deal. Now, when you hear this statement, I think most clinicians immediately hear the excuses and the barriers and the sustained talk. But what I want folks to recognize is that during the evoking phase of motivational interviewing, our task is very straightforward. It is to focus entirely on this part of the statement. This part of the statement is change talk, it is a potential reason why this individual may decide to change the behavior. The sentence that comes before it and after it are sustain talk. What we want to do during the evoking phase of motivational interviewing is to have a laser sharp focus on the change talk, and then do something about it. In this case, you reflect that. You feel a little foggy the next day, that's a simple reflection. And then immediately follow that up with an open ended question, tell me more about that. In this example, we're completely ignoring the sustained talk, we're letting it go, we're not even going to address it. We're not going to argue with it, we're not going to do anything with it. We're going to focus entirely on the gold that we have in front of us, which is the change talk. We're essentially saying, I like what you're saying right there, and I want to hear more of it. Another response might be, you're worried about how it's affecting your work. That's a complex reflection. What do you already know about how alcohol can affect your brain? That's following up as sort of a question about it. Let's see another example. It's such a hassle to take my medications. I known I'm supposed to take them, but I don't even have them with me half the time. There are good reasons to be on them, but it's just no possible. Again, when clinicians hear this we immediately hear the excuses and the reasons for why this person doesn't want treatment. But if you actually look carefully, you'd begin to realize that there's change talk embedded within this statement. I know I'm supposed to take them is change talk. There's good reasons to be on them is change talk. And it also turns out half the time, I don't even have them with me half the time, implies the person has the medications during the other times. So this also is a subtle but a type of change talk. So reflection or responses might be something like, you have good reason to take them. Tell me about them. We're ignoring the excuses, we're ignoring the sustain talk, and we're focusing entirely on the change talk. And again, our goal is to evoke and strengthen change talk selectively, and it turns out this is not easy to do right away. As you begin to learn motivational interviewing, a skill that clinicians have to learn is to be able to distinguish and recognize change talk versus sustain talk as they're coming at you in real time. That takes quite a bit of practice to be able to recognize them, remember them, and formulate a response as you're hearing the patient speak. Another example, despite the hassle, you find a way to take them some of the time. How are you successful half the time? And that kind of gets into the taste of my questions about the ability. How would you be successful? So this is asking, how are you successful half the time? That gets back to the prior successes again. So I hope that these are themes that emerge to help you sort of think about what types of questions you might be asking patients. Let's see one more final example. I don't want any medications. I want to stop using heroin but I've tried detox five times already. I've know buprenorphine can help, but I don't want to get hooked on that. I want to do it my way. Again, when you first hear this it sounds like a bunch of reasons to not engage in treatment. But when you begin to look at it, you do see that there's change talk embedded in it. I want to stop using heroin. I've tried detox 5 times. Buprenorphine can help. So all these are actual change talk that we can target. You know should stop heroin, tell me about that. Or you've tried many things to stop heroin, what do you already know about buprenorphine? So again, these are examples of how to evoke and strengthen change talk. And this strategy of taking change talk out of the statement that the patient just uttered is, we call this snatching change talk out of the jaws of ambivalence. Because in reality, ambivalent patients talk like this all day long. They say I want to change, I don't want to change. I want to change, I don't want to change. And our task is to clearly separate the two. And in a way, by reflecting it we're showing the patient all the good reasons why they're saying they want to change. In fact, I think many patients don't even realize themselves that they're saying the change talk that they're saying. So our job is to be aware of them, to recognize them, to evoke them, to affirm them, validate them, reflect them, and be nice to the change talk because that's what's going to lead to change, not simply addressing the sustained talk and the barriers. And when you hear change talk, it is important not to ignore it. As you saw in the example before, we want to do something about it. We can ask for elaboration, tell me more, or ask for examples. We're affirming, say affirming the positive qualities or the efforts that they're putting into it or reflecting it. So these are all strategies to keep talking about the change talk and the reasons why the person wants to change. So we went through engaging, focusing on avoiding the writing reflex, diverse training to listen, demonstrating empathy, and then making sure that the agendas are aligned. And then you're working to evoke and strengthen patient's own reasons for change by focusing on strengthening and invoking change talk. And then finally, we get to the planning phase. And once you've done that, it becomes a chance to see, to probe, whether it makes sense to kind of go forward with coming up with a plan. And it's about translating all that motivation into actual action. And the strategy that we would recommend is using what's called the change talk bouquet as a transitioning point between evoking and planning. The bouquet represents all the change talk you've collected throughout the encounter. And we kind of envision this as you're interviewing the person, you're walking through a field, and there are many things growing in that field. But the particular things that you want to collect are the flowers, or the change talk, and there are other things that you're ignoring. Sustained talk, I don't know what kind of plant they are, but all I know is that the change talk is prettier. And you're going to collect them. And during this transition you're going to collect them into a bouquet and show them to the patient. You're showing to the patient saying, look at all the pretty things you're telling me why you want to change. So here's an example. You're tired of being strung out on pain meds. You spent a fortune on them already, and your wife is threatening to leave you. You've heard good things about buprenorphine and you're willing to try it. So where does that leave you? Now this last question, we call this the key question as a way to, so you give the change talk bouquet and you're essentially asking, what are you going to do about it? You told me all these reasons why you want to change, so what are you going to do? That's called the key question. Let's see another example. You're beginning to worry that your drinking is actually a little out of control. And the DUI last week was a real wake up call. Even before today, you've been thinking about doing something about it. Where should we go from here? Again, change talk bouqueting, keep question combination though. Another final example. You've watched too many friends overdose and you're sick of living like this. You've done well when you're in treatment and you want to get back to your career and things that are important to you. You're determined to get off of heroin. What will you do? Another change talk and key question combination. And this is somewhat of a pro. You're trying to gauge where the patient is that on that hill that I showed earlier. If a patient response, the key question by saying, I don't want to do anything, I don't want to change at all. The suggestion may be that you're at the bottom of the hill. And then your task is to do whatever it takes to inch up the hill little by little. On the other hand of patience replies, I think I need some help can you help me? Then you know that your further up on the hill. It doesn't mean that the change will occur perfectly in the patient going to stop using heroin that they'll be perfect no but at least have an indication. The patient is further up on the hill and is willing to at least have a conversation about planning next steps. So if a patient is willing to do something that's terrific. It's important to focus on what's called smart planning which is [COUGH] planning on coming it's very specific and measurable and timely and realistic. And then there's a time to explore different options and then offer treatment at your own click or off site for medication for counseling, etcetera, if the patient is not yet willing. Then it becomes important to reinforce it, you want to continue discussing this. And then what's going to happen is you're going to repeat this process of engaging focus and invoking. Yet again, because again, our task is to do what we can to lift up patients motivation up higher on this hill. And again, there's no fantasy that a five minute competition alone is going to do it. So if the patient is still not yet willing, it doesn't mean that your intervention has failed. It simply means that your task is to continue that and to do what it takes to raise that motivation higher over a period of time. And I think this is very important to many clinicians believe that after doing motivational interviewing after ten minutes, that if the change doesn't occur, that it didn't work, and I want to, I don't want clinicians to feel that way because again, our task Is to focus on the intervention, not the outcome. And our task is to focus on delivering evidence based intervention for a particular patient who needs to be motivated. For example, SMART Planning will be the goal is to initiate treatment for opioid disorder, that they can begin to men to stop using heroin, that they've done it before they can do it and they'll call the clinic today to set up an intake. So going back to our initial hope here, that if you're able to implement motivational ambulin, that you'll feel less frustrated having these conversations and then actually be more effective in helping patients change. What's critical is that motivation is a skill. It is not knowledge. If you do not practice motivational being you will not improve in skills. Therefore it's important to continue practicing it. And that, you know, we asked our patients to take risks by doing, you know, going to treatment, for example, that's scary. And I think we can ask ourselves to be courageous as well. In fact, each patient that you do this with and practice with will become your teacher because if they're giving you lots of change talk. You're probably doing something right. I think given a lot of there may be rooms for some improvement in doing better motivational. That's not always the case of course. Some patients will only give you the symptoms but the point is if you're getting a lot of keep doing that. What's really critical during practice is to get feedback. This is true for many skills that you have to learn, whether it's a musical instrument or sports, it's hard to get better without getting feedback. So implementing some strategy to do that, we would highly recommend whether it's a audio recording or having somebody Listen in to your conversation. Generally speaking, a workshop training that lasts an entire day, or two, or three is considered one of the best ways to get you up and running in practicing motivational. Unfortunately, this one hour alone is often not enough. So we would highly recommend looking for Workshop training where you do a lot of practice with others. Another is to do coding training for motivation, learning, or even learning to be a trainer, yourself these other options. As well. There's a website called www.motivationalinterviewing.org. And it's full of resources, videos, DVDs that you can purchase. Looking up trainers and other events, motivationalinterviewing conference. So I recommend you look at this if you want further information about motivational interviewing. And also, I want to point out there's two books that are particularly effective in building skills. One is by David rosengrant. Let's see it's in the references. David rosengrant, building motivational living skills. Other is called Motivational interviewing and healthcare by real Nick Miller and Butler. And those are the two texts that are, are frequently recommended for clinicians to build skills around motivational interviewing. So very quickly, I would like to make you aware of two resources offered to PCSS-MAT that may be of interest to you First, PCs MCs mentoring program is designed to offer mentoring assistance to those in need of more one on one interactions. With one of our colleagues address clinical questions. You have the option of requesting a mentor from our mentor directory or we are happy to pair you with one. To find out more information please visit our website using the web link noted on the slide. Second PCSS offers a discussion form which is comprised of our PCSSO and PCSS MAT mentors and other expressions that feels will help provide prompt response as clinical cases in question. We also have a mentor on call each month that is available to address any submitted question through the discussion forum. You can create a new login account by clicking the image on the slide to access the registration page. And this slide simply knows the consortium of lead partner organizations that are part of PC SS MAT project, as well as our contact info, website and Twitter handle to find out more about what we offer. And that concludes our presentation on motivational interviewing. Thank you very much.
