Hello, it's great to be here with you today to talk about this really important topic that I have a lot of passion about. Motivational interviewing, increasing trust, engagement, and moving toward positive change. But first, as usual, we'll get started talking a little bit about the Opioid Response Network, which brings this programming to you. The Opioid Response Network is a federal program that's made available through SAMHSA, the Substance Abuse and Mental Health Services Administration. We provide technical assistance or consultation to support evidence-based prevention, harm reduction, treatment, and recovery practices around opioid use disorders and stimulant use disorders. Again, we use local, experienced consultants across the continuum of care to help communities and organizations address the opioid crisis. We accept requests from anyone on education and training. Each state or territory has a designated team led by someone that's called a TTS or a technology transfer specialist. They're an expert in implementing evidence-based practices, and they will be the one that would connect you with a consultant to give you some support with whatever you're working through. So to ask questions or submit a request, my favorite way to submit a request is through opioidresponsenetwork.org. The top right-hand corner, you'll see a button that says Submit a Request, and it makes it very simple to submit a request within 10 minutes with information that you'll know off the top of your head. So with that being said, a little bit about myself in case you didn't catch one of our previous presentations. My name is Scott Lueggenau. I'm a man in long-term recovery from alcohol and drug use. So for me, that means that I've been able, since 2011, to live a wonderful life without the use of alcohol or other drugs, which has meant a whole lot to me and my family. And it's made it possible for me to get an education, I became a master in social work, and to come back and do presentations like this for groups like yourselves who are doing great work for the people really who need the support at one of the most important times of their lives. And I know what that feels like to the extent that I can, right? I own Gatespring Consulting. I do a lot of consultation through the opioid response network and work with a variety of these other logos and organizations that you see listed on the screen. So very happy to be here with you today, talking about motivational interviewing, which is a real gift, and in a lot of ways, I think an underutilized gift in our field. We have a lot of folks that will go to one MI training, motivational interviewing, and say that they have been trained in motivational interviewing. Well, really, there's a lot to motivational interviewing. It may seem simple, and you may think that you're already doing it, but really, it's an organized practice and a way of engaging with the population that you serve to really have the greatest impact. And we know a lot of things about the human being and the ways that we like to be told what to do and don't like to be told what to do. And so motivational interviewing really digs into that. It was started in the 1980s with William Miller and Stephen Rolnick and what they found in their research that they were doing with individuals who were suffering from alcohol use disorders or addictions to alcohol, where folks don't like being told what to do. And we'll talk a little bit more about that going forward. And sometimes as peers or as folks that work in the field who have recovery experience, we want to tell folks what worked for us, right, and that can be really impactful and really helpful. Well, it has to be stage appropriate. What does that mean? Well, the individual has to be ready to hear that suggestion, and our suggestions aren't always taken well if we're not practicing motivational interviewing. So we'll talk about that. We'll talk about what motivation looks like for an individual. And we'll talk about the role of peer support specialists. We'll talk about assumptions, different processes that are important in motivational interviewing. And as well as the skills and the benefits that come along with motivational interviewing, we'll talk about the five stages of change. So with that, we'll just jump right in. So this is really a new look at motivation. Motivation is really the key to unlocking behavior change, and for many of us in recovery, we can remember a time where, you know, we were told time after time that you need help or you need assistance. Well, it wasn't until we decided that we really wanted to do the thing that we were really able to move forward and to make those really positive steps forward. And so we want to understand more about that. We all understand how that can be important in helping people, you know, sort of help their issues around problematic alcohol and drug use. We're going to talk a little bit about the nature of motivation. There's a difference between intrinsic motivation and extrinsic motivation. So extrinsic motivation might be my spouse or my job or, you know, the ability to stay free instead of becoming incarcerated depends on me making this change, whereas intrinsic motivation is more about I've got this set of values as Scott. I know that I don't want to continue a life like this for the rest of my life, right? And that's an intrinsic motivation. We know that intrinsic motivation is really, really strong. Extrinsic motivation can be strong, too, depending on the person. But we know that intrinsic motivation can be the stuff that really sustains long term recovery over the course of an individual's life. And we know that this is all about being ready, willing and able to make a change, right? Intrinsic motivation is really, really hard. Sometimes we forget that in our field when we have folks that are coming in, they've been using this substance or group of substances as their primary coping mechanism for years. And this person may have been through, you know, complicated trauma histories. We never know what an individual is experiencing, right? They could have co-occurring disorders, bipolar disorders, schizophrenia, depression, anxiety, all of these different things, right? But we know that motivation is so important in this aspect of making the decision, like this Olympic effort to overcome something that I've been doing for years and years and years that's worked in some ways for me, it's helped me to forget about problems or whatever it's done until it's not working anymore. So that's what motivation is all about, right? It's deciding for an individual what is going to motivate them to make a decision, a real life-changing decision to go into long-term recovery, whatever that looks like for them. One of the important things to note is reactants theory. And I alluded to this a bit earlier, but reactants theory is this legitimate theory that was found through motivational interviewing research is that we don't like being told what to do. So any of us that have children or who are children to parents understand this. We just do not like being told what to do. In fact, what we found is, you know, when we start telling an individual to do something, even if that individual would have come to that with their own conclusion, that that individual will start thinking in the back of their mind, all the reasons that they don't have to do it that way, or they don't have to do it at all. So we can have a negative impact on others by telling them exactly what to do in certain circumstances and it can actually have poor outcomes, right? We consider that an authoritative approach. We talk a lot about having different multiple pathways to recovery, but oftentimes we don't really allow that for the individual. And so when we take this authoritative approach with the individual and their recovery pathway, it can often backfire and lead to, you know, a return to use or continued use if there are any still using. Resistance becomes reactants. There's a natural amount of what we would call resistance or actually ambivalence is the way that we put it now is when you talk to an individual, their life's falling apart around them, that they continue to use cocaine, well, they're ambivalent about whether or not they should stop. What does that mean? They're just not sure. They don't know if they should stop. Why? Well, there's positives on both sides. There's positives to quitting and then there's positives to continuing to use for that person for whatever reason, right? Maybe it just helps them to forget about something. Maybe it helps them to push through uncomfortable circumstances, but whatever it is, there's something, maybe it's just the comfortability of using a substance that you've used over time, right? Whatever it is, we're going to find ambivalence and we should not be shocked when the individuals that we're serving are ambivalent about change. And if we try to push them too fast along this sort of continuum of change or try to instill extrinsic motivation into them, that can really backfire. Instead, we really want to cultivate this high level of empathy, right? Like I see you, I can see what you're going through and we want to ally with them. We want to be their ally. We want there to be this therapeutic alliance where they feel comfortable coming to me and telling me how they feel. We want them to feel comfortable that we have their best interest in mind. And that's a very, very important part of motivational interviewing. So we'll continue forward. So there's this different perspective, right? We used to take a very authoritative stand in addiction treatment. Over time, we've seen that sort of evolve into something different, especially with a sort of field-wide adoption of motivational interviewing. And what do we do? What do we do now? So instead of being sort of a weakness-based, we are strengths-based, sort of we're looking inside that individual to figure out how we can complement them. What are their strengths? You know, what are those strengths that they can build on as they move forward into this very difficult journey of recovery? We want to make sure that it's individualized and person-centered, our approach to treatment. We talked about that in our last presentation, this idea that there's not really a one-size-fits-all approach to treatment. And so really the onus is on treatment centers to really become a little bit more flexible in how they work and not sort of put out a cookie-cutter approach to everything. We want to shift away from labeling. We know that words like addict and alcoholic, just through research, we found that they have pretty damning effects on individuals who suffer from substance use disorders and the perception of folks in society around folks who struggle with substance use. I know that those terms are very common and welcome in our mutual aid groups, our 12-step facilities, and that's okay, right? It's a different environment and people should identify as what they want to identify as. But when we're using language to discuss these issues around recovery and addiction, we should really use terms like, you know, person is still in active addiction, they have a substance use disorder, they're in long-term recovery. We don't say that urinary drug analyses are dirty or clean. We say they're negative or positive for, you know, X substances, things like that. Labeling is important. Therapeutic partnerships, again, we talked about that therapeutic alliance. That's the number one thing of importance to clients. They want to be allied with the person that's providing services to them. Whether it's a therapist, a case manager, a peer, it doesn't matter. We want that alliance. We want that from doctors and healthcare providers as well, right? It's important. Providing a service. We want to be empathetic. We don't want to wield power or come from the place of ego. When we're working with individuals, we're talking about people's lives literally being on the line. So it's not a time for selfish ego play. It's time to become empathetic and to slow down and to understand where is this person coming from? What are they experiencing right now? It's about early and brief intervention, right? When we're doing motivational interviewing correctly, we can start to engage with that person very early on, building that rapport, and then as soon as they're ready to start making those changes, we're ready to assist them in that process, but not push them into any process. And it works across the continuum of substance use. Well, what does that mean? You know, whether it's mild, moderate, or severe, whether a person is just experimenting with substances and they haven't had a ton of problematic consequences yet to the person who is, you know, unhoused, who is living on the streets and using as much as they can use, right? Like motivational interviewing is a great intervention for everyone, no matter where they are. And their acceptance of new goals, right? We want to accept that our clients may have different goals than we have for them, and that's okay, right? We want to work with them where they are until they're ready to make that next step to a goal that we may be more interested in them sort of achieving. But really, that person has to go through their own journey. And then risk reduction is a big focus of this new perspective, this idea that we do want to reduce harm, right? We reduce harm in all other aspects of healthcare, whether it's diabetes, asthma, or whatever chronic long-term condition that you're talking about. We should also be interested in reducing risks around addiction. It's not enabling, it's simply, you know, keeping that person alive until they're able to access care or they've garnered enough motivation within themselves to start making those positive changes. So what about the role of peer support specialists? How is that sort of coherent or congruent with motivational interviewing? Well, peer support may boost self-esteem and confidence. We've seen that in research. This is also a piece of motivational interviewing is this idea of we want to affirm the strengths of the individual. We want to seek those out. If we're really getting to know the people that we're working with, we'll find those things to compliment them on and give them those positive affirmations. It raises empowerment scores with the individuals that we work with. We see that with motivational interviewing and when peer support is doing a great job. Positive reception of treatment. I always call peers the concierge, you know, if you go to a fancy hotel, there will be a concierge in the front and you're new to a city, it's like, you know, what do I do here? These are the things that I'm interested in. Well, I consider peers as the concierges of recovery, right? It's this idea that recovery is foreign to many folks that come in. Peers using motivational interviewing or counselors using motivational interviewing actually start to raise the empowerment of the individuals that they're working with. We see this positive reception of treatment because you have this person who is saying, I got you. This is actually the treatment that's probably going to be best for you. Let me know what you think about it. Is it okay if I share a little bit of information about it, right? And then you're able to give them some different options. And that's a beautiful thing for the individual who might not have gone to treatment at all had they not had that sort of peer who intervened and were able to say, let me just tell you about this. It's not as scary as you might think it is, right? It increases hope and inspiration, both peer support and motivational interviewing, increases camaraderie between the client and the practitioner, the provider, the paraprofessional, the peer, however you want to say it. We see that therapeutic alliance, which is what we're looking for, decreases psychotic symptoms and substance use. We see that with peer support specialists who are doing work with clients and then along with MI, it also reduces hospital admission rates, right? So all really, really, really important things to consider. But what is motivational interviewing really? It's a collaborative conversation style that strengthens a person's motivation and their commitment to change. So specifically, it's a conversation about change. How do we talk to people about change? It's a style of guiding, not extreme or forceful guiding, but gentle guiding appropriate for where that person is. So it's not guiding right up front, we got a lot of rapport building to do up front, which is gaining trust with the individual, understanding that ambivalence is normal. This idea that we're not so sure if we want to quit or not, like that is extremely normal for somebody who is in the pre-contemplation stage. They haven't thought about quitting yet, or in the contemplation stage, they're still contemplating which life is it going to be for me. And that's really hard for people that have lived a certain life for a long time, right? People are more likely to be persuaded by what they hear themselves say. This is, I can't stress this enough, right? We want to be, and I think this comes down to ego sometimes, but we want to drop the knowledge on folks, right? But really, when they say these things for themselves, if they come to these conclusions to make these changes for themselves, through motivational interviewing, which is this style of sort of talking with them, it's much more powerful. So my first supervisor, clinical supervisor, was a real expert in motivational interviewing. He was certified motivational interviewing network of trainers. It's pretty rigorous to do that. And he would say, Scott, you never want to take away your client's best line for change. And at first I was like, what does that mean? And then he explained, if you can get the person to say the thing just through your conversation with them, it's going to be so much more powerful than if you said it. So if I say, well, maybe you should consider treatment, right? Versus them coming to the conclusion, maybe I should consider treatment. That's going to be a very, very different sort of situation, right? When they hear that come out of their own mouths, and it's their own words, you can't put a premium on that. That's major. All right, so we'll keep going. Assumptions of MI. You know, ambivalence, or it used to be called resistance, is sort of the enemy. We know that this is sort of a typical barrier, right? But we also know that there's a lot of people that come in, and they are ready to change. And maybe that's not where MI is as appropriate, right? You can still use it because you always want to build rapport, and you always want to have open-ended questions and empathetic sort of style of conversations. But we also understand that you have both, right? And we understand that ambivalence is seen as a barrier, not really a barrier. It's just something to be expected and to work with. We resolve that by exploring the client's motivations to change. We'll talk about that. The client-specialist alliance is key here, absolutely key. This is bore out through so much research that has nothing to do with MI. We know that that alliance is super, super, super important to whether an individual is going to either engage in recovery or sustain long-term recovery. We know that a supportive style, not an authoritative style, leads to change. So what is MI specifically? How is it done? Well, we're sort of zooming in and getting closer to that. There's four different processes of motivational interviewing. There's engaging, that always comes first. You can't skip ahead with this. I've got a current supervisee who I supervise. He's a licensed clinical addiction specialist, and he is ready to just lay the knowledge down on his clients as soon as they get there. And I said, you're rushing this process, and you should be enjoying the process of engaging with the client first. Tell me about yourself. Where are you from? What kind of food do you eat there? Tell me what you like to do. Tell me about your relationships. Tell me what's brought you here today. Tell me about how this has been a difficult experience for you. I know it must have been. But really engaging with that person, because if you start to force feed them things early on in the process, they might throw you into a bucket of people who they consider to not really care about them, and their needs, and what they want, and who they are as a person. And we need to learn as much as we can about people to help them. It's very important. The second piece is focusing. It's finding direction, right? Sort of taking everything that this person is telling you and then starting to use motivational interviewing to guide them a bit, guide the direction of the conversation a bit more after you started that engaging based on the information that they're giving you. We'll go into that. Evoking. This is really important. What does evoke mean? It's just like to bring about, right? We want to evoke within that person motivations. How do we elicit motivation in someone else? There's some tricks and tools that make it, I don't want to say tricks, but there's some tools that make it a lot easier of a process. Planning, right? So when it's stage appropriate, we're ready to plan. So for the individual that comes in and they're like, I am here, I'm motivated, tell me what to do, what I've been doing is wrong. You can almost, you can do a little bit of engagement, right? Just to kind of soften that relationship and gain a little bit of trust. But for that person, you might want to jump into planning, right? That person is motivated to plan. They've got the motivation. We don't have to elicit it from them as much as we have to help connect them to different resources that are appropriate for them, right? So we still have to ask enough questions to determine who they are and sort of what may be helpful to them. And then you have these core skills. We're zooming in a little further, right? And you can remember them by the acronym ORS. And it starts with open-ended questions. So this invites storytelling. What do we do a lot of times in intake procedures in our different facilities? Well, we start asking a bunch of open or, excuse me, closed-ended questions, either yes or no, or, you know, have you received treatment before? Do you have a primary health care provider? Blah, blah, blah. You're doing this 200 questions. By the time you're done with that, who could blame anybody for, you know, being triggered and maybe wondering if this was the right decision. By asking them open-ended questions, and this was another thing that my former clinical supervisor told me was you have to ask those open-ended questions, not only at the beginning of a conversation, but do it at the end, right? So if we have a session and we're there for 20 minutes, 30 minutes, 60 minutes, we're doing an intake and it's two and a half hours, whatever that looks like, we start, we always start out with open-ended questions. Yeah. Tell me about the last week since I've seen you. I've been thinking about you, how have things been going for you, right? What has recovery looked like for you so far, right? Have you noticed any changes? And if so, you know, tell me about like the changes at work or with your relationship, right? But this invites storytelling because if we let a person say yes, no, and just give one word, sort of one phrase answers, we will get that. And we will likely not learn as much about them as would be helpful to help them in the future, right? And then affirming, expressing positive regard. This is one of my favorites, this idea of you might be working with a person who has not received a compliment, a sincere compliment in a very long time. Motivational interviewing says search for that person's strengths, you know, and if not for anything, the strength that they muster to get there today to talk to you or to get onto a Zoom and talk to you or like whatever your atmosphere is. But that's something to get on and talk to a near stranger about what you're going through. So we always want to look for things that we can say, hey, I just want to say, you know, I've noticed this about you and it's, I think it's great, you know, or make it authentic to you, however you want to say it. But the idea is you're finding something positive to point out in that individual. It's a key to motivational interviewing. And then reflective listening, right? We want to express empathy. So when they talk to us, are we listening in a way where we can reflect back what they're saying and what does that do? Well, that shows them that we're listening, that we understand and that we want to know more. If they get a sense of at any point you're not really listening to what they're saying, that's going to really not do a lot for the therapeutic alliance and that camaraderie that we were talking about a little bit earlier. So we really want to express empathy. So if somebody has told me something very heavy and deep, I am going to be right there with them, listening to them intently, knowing that this is a very sort of sacred thing that they're sharing with me. And then I'm going to reflect it back and say, God, that must have been so hard to go through. You've lost your mother in this process. You've lost your spouse. You don't have custody of your children right now. You're in this place of you feel like you've tried everything except treatment and here you are now. I just want to say that I hear you and I'm really glad that you're here. I'm honored to work with you. And I also want to say that you're a real survivor. So going back to the affirmation, you're a real survivor, all of this that you've gone through. And I will say that I've worked with many, many individuals and they've been in very difficult circumstances and they're now living in long-term recovery. So giving them that hope as well, right? It's always important, but the reflective listening, you've got to listen and you've got to be able to sort of summarize quickly what it is that they said or a sentiment to sort of reflect back to them showing that like, yeah, you're right there. You know, the heaviness of what they're going through. And again, sort of summarizing, this is different than reflective listening, but a lot of the same where it's like, you get through an entire session or whatever your contact is with this individual, but towards the end, you want to make meaning of everything that you've talked about by summarizing. And what do you do? Well, that looks a lot like just giving a brief synopsis of the entire event that you've had. Okay, you came in today, you said you're feeling a lot better. There's some things that you're working with that you felt a little shaky on, you know, going to the bus stop in the neighborhood where you used to cop substances from, that's created, you know, we talked a little bit about some mindfulness techniques there. We're doing a little bit of motivation or a little bit of mindfulness meditation. You know, you feel like over the course of the next week, you want to try those when you're feeling stressed out or when you start thinking about using. Anything else that we missed that we talked about today that you wanted to sort of end this on, right? And sort of just sort of summarizing. So, open-ended questions, affirming, reflective listening, summarizing. If you can remember those four things, that's a great start into motivational interviewing. This changes your whole approach, right? We also train doctors on motivational interviewing. So, think about it. If you had doctors that were using these skills anytime that they saw you, wouldn't our healthcare system be so much better? Well, we know this works with addiction. And again, it's life or death. So, we want to do the right thing. So, what's the benefit of MI and substance use disorders? Well, you know, working with individuals with substance use disorders, well, it's easy to use. And I won't say it's easy to use. There's an ease of use if you are familiar with it, right? Like if you really sort of understand motivational interviewing and you're really trying to sort of reflect in your own approach to things, how am I talking to people? How am I asking questions? And you make that a part of your mantra every day. Going into your first sort of contact or conversation with somebody, how am I going to implement these MI skills around open-ended questions, affirming, reflective listening, and summarizing. It starts to become sort of natural in your everyday conversations. It can be sort of helpful in your interpersonal relationships as well. MI is crucial to making people feel heard. So, I'll just say that. Applicability. We know that it's highly applicable to folks with substance use disorders. The research around MI was started looking at folks with alcohol use disorders. We know it works really, really well across addictions. Effectiveness. Again, we know it works really, really well. We've got the research we know. And the ease of adoption, right? You really could make this a personal or organizational quest and have a whole different culture in your operation in pretty relatively short form. What are some roadblocks to active listening, which is one of the crucial elements of motivational interviewing? So, I like these. These are Gordon's 12 roadblocks to active listening. Ordering, directing, or commanding. When we start taking that tone in a conversation, the person stops listening to us and then we lose all trust. Warning, cautioning, or threatening. If you don't stop drinking, you're going to die, right? And I know that seems very palpable and very sort of natural, especially with the advent of fentanyl and the poisoning of the drug supply and knowing that people are dying every day, every second. But warning them, cautioning them, or threatening them isn't telling them anything that they don't know already. You think they don't know? They do know, right? All of us who use substances knew, for the most part, the impact that it would have. And there are some folks out there that don't, right? But probably not the individuals that you're going to be working with. Giving advice, making suggestions, or providing solutions prematurely, or when unsolicited. This is where we go wrong a lot in our field is we go right to giving advice and saying, well, this is what you should do. And we know that that doesn't work very well, right? It has to be stage appropriate. When I first start giving advice or suggestions to somebody that I'm working with, I will ask for permission, right? I will say, hey, you've told me that you've struggled with this specific thing. I've worked with a wide variety of people that have struggled with similar things. And I know a couple of different options that could be helpful to you. Could I share those with you? And then you tell me what you think about that. And that's a much less threatening way. And it gives them a lot more sort of leeway to make it their own idea when you're saying, let me just say, you might not be interested in it. These are things that work for other people. And they might pick on one of those things and say, yeah, you know what? I think that sort of sounds interesting. I'd like to try that, right? Persuading with logic, arguing, or lecturing. This is very sort of part and parcel to these other active listening no-nos. We don't want to lecture or argue. We never want to argue with a client. We've lost as soon as that's happened, right? Moralizing, preaching, or telling people what they should do. Again, these all have sort of similar flavors of the same thing. Judging, criticizing, disagreeing, or blaming. And you might be thinking, where does this happen? It does. It happens. It happens in treatment. It happens across healthcare settings. So it's really important to know not to do. Again, we want to talk about road blocks to active listening. So praise, or approval, or agreeing can be an obstacle if the message implies agreement with whatever the client has said, or if the praise is given too often, or in general terms, like great job. So let's talk about the difference between an authentic affirmation and what they're talking about here. This is sort of canned stuff where you're just like, you're doing great. That's a great job. Authentic affirmations looks like, oh my gosh, I remember when you came in last week and how hard things were for you. It is remarkable to me, the progress that you've made in a week already based on X, Y, and Z. You see how those things are different. I'm giving them real palpable, detailed sort of feedback that is based on reality. And they're going to recognize that. They're going to be like, yeah, I did do that. Yeah, they do see me making progress. So shaming, ridiculing, or labeling, of course. Interpreting or analyzing. We don't want to come to conclusions about what a client is saying without fully knowing that's what they're saying. What does that mean? Well, it means if we're not sure what a client is saying, a big part of motivational interviewing is repeating it back to them to make sure that you understand. How would you do that? Well, if a client has said, you know, I'm really, really, you know, I'm feeling good about not using cocaine, but cannabis has been really, really difficult lately. You know, I would simply almost repeat it back to them very close to what they said. I would say, okay, so, you know, you're feeling a little bit more comfortable and you're, you know, stopping the use of cocaine, but the cannabis has been, that's been a little bit trickier. Can you tell me how or why and what does that mean? Well, that means you've given them an open-ended question. You've clarified that it is truly indeed what they were talking about. And you would be surprised. You might feel like you really understand what somebody said. And there's a lot of times where they'll tell you, no, when you, when you give them a chance, when you repeat it back to them, they will tell you that indeed, that's not exactly what they meant, or it'll give them a chance to go a little bit further in by again, you asking, well, tell me a little bit about how or why, why is that happening? How is that happening? What do you, what's your, what's your sort of feelings around that? Reassuring, sympathizing or consoling. It's human nature for us to reassure someone who's in pain, but sympathy isn't the same thing as empathy. So we really don't want to interrupt the flow of communication. So why, why not? Well, if a client is in pain and first of all, pain is ubiquitous. It's part of life. It's part of the healing process. It has been for many of us. If they're sitting there and a conversation, and they're really going to a place where they're talking about things that have been inside of their head for so long, because they haven't been able to share that with a counselor or a peer or whatever, or a friend or a family member. Well, we don't want to stop them because oftentimes we'll stop them because it's making us uncomfortable. The pain is making us uncomfortable. So just check yourself on that and sort of say, am I sort of coming to their rescue to make myself feel better? Or am I coming to the rescue because they legitimately need me to? And if a person is sort of describing their previous substance use or the trouble that it's gotten them into, or their relationship with a loved one, that's difficult, let them keep talking and let them get it all out. And then when they're, and they've got it all out, you'll know, and then use reflective listening there. Questioning or probing, we don't, we don't want to do too much of that. Remember we talked about the 300 question, yes or no intake. We want to be careful with our questions. We want questions that ideally motivational interviewing, 80% of it is questions and 20% of, or excuse me, 80% of it is the person talking, the individual talking, 20% is us asking questions. How do we do that? Well, we ask the open-ended questions, right? We don't want to probe them asking just machine gun style, tons and tons of questions. Now we have to do that. Many of us in an intake procedure, but how do you, how do you do that again? It's, it's an MI sandwich. You put a little bit of MI on the front and the back. What does that mean? Well, before you start asking all of those questions, ask them about themselves. Hey, I'm Scott. It's so great to meet you and to work with you today. Tell me, tell me about yourself. I'm interested in learning about you and you might get a lot of that intake, the questions on your intake answered in that process. So you don't have to ask them then, right? You can just take those notes down as you're talking to them. And then after the intake, you're also going to do MI instead of just saying, okay, well, that's the last question. Good luck. And bye. You know, when, when the last question is over, you're going to do more of that. Okay. That was a lot. Thanks for sticking with me on that. I know it's a lot. Let's get back to what we were talking about before you said you're from Burlington. What, you know, what kind of barbecue do you guys eat out there? What, you know, whatever that looks like, but, or it could be really wrapping up after you do a little bit more of that report building and saying what would, what would, you know, a life of recovery look like for you, if you had to guess, like if you could, if you woke up tomorrow and everything was perfect what would that look like for you? Because I think that's how you, we could start working with you to, to create some goals, to really get you to a place where you love life every day. Right. And what's better than that? Withdrawing, distracting, humoring, or changing the subject. A lot of us who have come from an active addiction background use humor to sort of like provide levity. And a lot of us, you know, just in general do this, but when things start to become a little heavy, we'll use humor to diffuse. Right. And typically that's to make ourselves feel more comfortable. Right. It's just like, whoa, this person's going to a dark place. I'm going to use humor. So it, a little bit of humor in the right place can be fantastic. There's a lot of humor that I use in, in, in working with people. I think it's really important. But if we're using it to distract or, or to sort of diffuse a situation where an individual is really going through something that's heartfelt, that's the wrong place. So those are some roadblocks to active listening. What are the five stages of change and the trans-theoretical change model? Well, what are they? Well, here, here, here are, they are, what this does is it really is sort of a roadmap. It's a roadmap that can go forward and backwards. It can jump around as well, but this is typically what we see in terms of the different levels of motivation. It helps us know how to work with a client, right? If a client is in, or an individual person you're serving is right there at the beginning and pre-contemplation at three o'clock on this, this chart. What that means is they haven't contemplated not using yet, right? Like everything in their mind is the way that it is. They haven't contemplated a change and this could be any kind of change, right? This could be like eating, exercise, the way that I interact with loved ones, anything, you know, waking up more early, going to bed more early, whatever that looks like. This could be anything, but obviously for substance use disorders is what we're talking about today. And then you've got contemplation. So that individual has gone from a state of not even thinking about making a change about the specific issue to thinking about it a little bit. And we can recognize this in what we would call change talk, right? They'll start to say things like, oh, you know, this, the cocaine is so expensive. I cannot even afford to, I can't even afford to, to, to buy my child groceries, right? And things like that. So that is, you might be thinking, well, they're still in pre-contemplation. Well, they're not because they're saying they're starting to weigh some of the negative impacts of the addiction. And that's what we want. We want to elicit that change talk. And then there's preparation, right? They've gone from contemplating to making a change to preparing to make that change. So we just don't go straight from pre-contemplation into preparation, or we don't go straight from contemplation into action, right? We've got to prepare for the action. And what does that look like? Well, it could look like a number of things, right? If I was wanting to do exercise, I might be looking at different YouTube channels about exercise to figure out which of the millions of different sort of approaches do I want. And there's a lot of different approaches to a lot of the changes that we want to make as human beings. So then you get into the action stage. It's like, oh, okay, now I'm in treatment, right? I'm doing the action. I'm going to meetings. I'm meeting with my sponsor, like whatever it is, like whatever it is. I'm going to church. You know, I mean, I'm engaging there with a different community of people that are sort of, you know, supportive of my overall wellness and ongoing wellness and then maintenance. So you've done the action, then there's the maintenance. This is what long-term recovery looks like, right? Is maintaining those changes that you've made. And then if there's a return to use or relapse, you can recycle again and you go back to pre-contemplation. And then you can go from different sort of stages to the other. You can jump to different stages according on where you are, but this is a typical chart that you'll see when we talk about motivation to change. Let's talk a little bit about one. The first stage pre-contemplation, there's no thoughts about change. The goals are, we want to understand their behaviors and their resistance. Why aren't they, why haven't they stopped using? We want to express empathy and acceptance. We want to provide new information, right? So the individual who comes in and they're using cannabis and it's like cannabis has no negative health impacts whatsoever. And we know now more than ever that cannabis has a long list of negative health impacts. And if we feel like they're ready for that. It's just like, hey, you know what? I used to think the same thing. There's been so much research that's been done over the past 10 years about cannabis. Would you like to read any of it? And sincerely ask them. And if they're like, no, I'm good on that. It's not time to talk about that yet. They're pre-contemplation. But as many folks of pre-contemplation who have been cannabis users have said to me is, yeah, I'd like to see that. So I'll print off a few copies of some research and then just highlight some things for them and just be like, at the end of the day, it's your decision, but you should at least know both sides of this argument. So anyway, that's pre-contemplation. We're really trying to understand them, their patterns, their behaviors, why they've used, why they're considering not using or why they might not consider using. Are there things in their lives that they don't like about it? Pre-contemplation to contemplation, there's strategies here. When we see that the client is not concerned about the substance use, we know that they're pre-contemplation. Again, our focus then as a peer or a counselor or an administrator or anyone is to develop rapport and build trust. We want to start getting to know that person. We don't want to fast forward to, hey, this is what you need process. We want to raise doubts and concerns about the client's substance use. How do we do that? Just through engaging them in conversation. How is using cocaine or meth, how has that impacted your life? Can you tell me all the different ways that that is both positively and negatively impacted your life? When they start talking about the negative impacts, and there always are negative impacts, whether it's cost, estranged relationships with others, whatever that looks like, we know that really talking about that and getting them to say, well, these are some of the negative parts, that really has a big impact. What are the strategies there? Really eliciting the client's perception of the problem, getting them to talk about it. Tell me about your relationship with XYZ substances. How have they changed over time? Explore the events that led them to a conversation with you in the first place. How did they get to you? How did you get here today? Tell me a little bit more about that. Assess their stage of change and their readiness to change. You might have somebody that's coming in, you assume that they're in pre-contemplation, but actually this person is in action. They're showing up to you and they're motivated and they're ready to go. You're going to change gears and you're going to say, okay, well, this person's already in an action stage on coming into treatment. What are some other action items we can get them to do that they would like? Maybe it's a group that's meeting with people who are like them or whatever that looks like. Of course, you'll have these slides so you could look more closely at all these charts. Stage two, contemplation. There's a willingness to talk about what's going on. They're contemplating making a big change according to or a little change, whatever change. They're contemplating making some kind of change to their relationship to substances. Again, this is contemplation, so it's not commitment yet. There's ambivalence. There's non-change there. They're stuck in this place of continuing what they're doing, but they're thinking about it differently. It's really important to let them be in that place. What are the goals? We want to decrease ambivalence. What does that mean? Well, we want them to side more on the side of more healthy behaviors. We want to decrease this idea that continuing to use substances is going to be helpful for them and their long-term goals. We want to strengthen their intention. When we start to hear the change talk, well, maybe I could just use on weekends and not Monday through Friday every single day. It's just like, oh, okay. Well, why would you do that? What does that mean? Well, they're going to start telling me reasons why they shouldn't use drugs seven days a week. That's them telling me and not me telling them. That's the goal that we want. Well, why would you do that? We would never think to intuitively ask that because we're like, yeah, absolutely, do that, do that, do that. But we really have to ask, why would you do that? Tell me a little bit about the impact that you think that will have. What if you did that for six months? What do you think the impact would be there with your family and friends, with your job, with the custody situation with your children? How do you think that would change? And you might lead to more change talk. It might be like, well, to really do that, I've got to really quit and maybe just use on a rare occasion. It's like, okay, that's a step in the right direction. Well, why? What do you mean? Well, to get custody of my children, I have to test negative, you know, on X, Y, Z drug screens. It's like, okay, okay, let's change talk. You want to hear that coming from their mouth, not your mouth. If you're like, you know, you're not going to get custody of your children. If you fail this next drug test, that is not gaining therapeutic alliance. And they know that. So what are you at this point? You're a parent and we don't like being told what to do, right? All right. So contemplation to preparation, how do we sort of tip that decisional balance of like thinking about doing something to actually preparing to do the thing? Well, we want to look at the decisional balance. Again, we can explore the pros and cons with that individual. It leads to really good conversations. They tell us about the pros. We don't want to reinforce those pros. We want to reinforce the cons. So they tell us the pros. Okay. Okay. Okay. Yeah. And then we get into the cons and then you're asking more open-ended questions. Tell me why that's important. Tell me how that's impacted your life when they're telling you the cons. Tell me more about that. How has that impacted your family? How has that impacted your job? You know, and then they start, that's the talk. This is motivational interviewing. It's bringing them to a point where they're sort of further moving forward toward change because they're saying all of these things about how drug use actually is pretty crappy for them, right? And when it starts coming out of their own mouths, when we hear ourselves say that thing, it has a whole different weight to it. We want to emphasize personal choice here because we don't want to get into a situation where we're sort of moving from contemplation to preparation and it is like, okay, let's go. You know, it cannot be like that because they will stomp their feet down into the ground and hit the brakes. Here, we want to emphasize personal choice and say things like, you know, at the end of the day, like it's completely up to you. Like you can keep going the way that you're going or you could make some changes. It's totally up to you. I'm here to help you with whatever it is that you want to do. And then ask them, what would it look like if you were to keep going in the way that you're going? And for many people, that looks like death. For many people, that looks like losing custody for my children for the foreseeable future, right? And so that's why we ask this type of questions. But we do want to emphasize personal choice because that puts them into a place of comfort, letting them know that we're not trying to push them one way or another because it's like a car salesman, right? When you go to buy a car and you know that they have one agenda, so you don't trust anything that they say. So, if you feel like your counselor has one agenda or your peer has one agenda, you're not feeling like they're truly there for you. So, it's something to think about. Explore self-efficacy. What does that mean? Does this person have the ability to make these changes? And likely, they have the ability to make some kind of positive changes that would impact this negative problem that they have in their life. So, you want to explore that with them. How do you do that? You ask them questions like, how do you think you would do that? What would be the first step to doing that, right? And then you get some of those answers like, okay, well, I could stop using seven days a week and I could just use on weekends. And what you want to say is that's a horrible idea. You should stop using altogether and that's the best way. But what you'll find is that even if the individual does do that and they use on the weekend, they see that they can't sustain that. It's not something that they can do. They'll come back and they'll come back with a different attitude about that idea. And they might be more interested in trying a more drastic solution or something that leads to long-term recovery, right? So, we want to ask the right questions again, open-ended questions. I think everyone gets this at this point. Closed-ended questions lead clients to answering in a particular way rather than answering freely and narratively. What does that mean? It's like, if I'm coming into treatment and I'm Scott, I want to know Scott. I really do, right? And so, we ask yes or no questions. I don't get to know Scott. I just get to know sort of just the smallest window about this person. So, if I can get Scott talking, then I can really get to know him. Stage of change three, which is preparation, right? They've made this decision. Okay, I'm either going to take this very small step or this very large step, all depends on the person. How do we sort of galvanize or solidify their commitment or their desire to change? And how do we anticipate problems or road bumps and have conversations around that? And then our goals are to prepare for action and to really create a plan there. And this is what DiClemente says, he was the researcher and author who created the stages of change. And he says, the preparation stage of change entails developing a plan of action and creating the commitment needed to implement that plan. Okay, well, what would it look like to only use cannabis in the morning, or excuse me, the evening, as opposed to waking up and smoking all day? How would you do that? What are the mechanisms that you would put into place to make sure that you're not tempted? All the way to complete abstinence, where it's just like, okay, cannabis and cocaine have been your things. How are you going to make sure that you're not tempted by those things? You're not coming into the same orbit as these folks that you know, that's what they do every day, right? Like, how do we make that plan? And the decisions do not translate automatically into action, right? It's not that simple. And most of us should know that if we think about tough decisions that we've made, it's hard, right? It's hard to lose weight. It's hard to eat differently. It's hard to exercise. But to change a behavior, one needs to focus attention on breaking the old pattern and creating a new one. And this preparation stage, this planning is really the activity that organizes the environment and develops the strategies for making that change, right? Reflective listening responses are simple. You can repeat or rephrase what a person is telling you, right? Like I mentioned a little bit earlier, it can be quite simple. As simple as almost repeating verbatim back to what a person is saying. It's better when you rephrase it in your own authentic language. When a person is just like, man, I cannot keep drinking like this. My husband's going to leave me this, that, and the other thing. And then I repeat back to them, it's like, you've had enough, right? This has beat you up and you have had enough and the people around you have had enough, right? That's reflective listening. And they'll be like, absolutely. Yeah, I'm done. Complex, right? There's different ways of doing this. So you can sort of zoom in a little bit into what the person has told you and then make some educated assumptions about what it is that they're going through. So that could, a person is telling me that they're fed up and that they've got to quit drinking. Everyone in their lives is turning their backs on them. And I can sort of zone into the feeling of that and say, you are exhausted. You're emotionally and physically exhausted with this, right? Complex listening response. I could ask them to dig into the meaning of what they said, right? So they tell me something, tell me a little bit about what that means to you, right? And your life, right? I'm doing this, that, or the other thing. Tell me what does that mean for you? Like, how does that impact your life? Double-sided, where you're sort of taking two sides of a situation, where it's just like you're doing the pros and cons on cannabis use with somebody. And they're like, yeah, it really helps me with my appetite. It helps me sleep better at night, but it also makes me really paranoid. It's really expensive. And I feel like I'm further isolating from my, the people who are most important to me in my life. Well, you always start with the negative and then you end with the positive. The positive being the reasons that they should change, which happens to be the negative impacts of cannabis here. So we would start with the positive on what they feel like cannabis is doing. Okay. So on one hand, you feel like it helps you sleep better. It also helps you with your appetite. But on the other hand, you're really struggling with paranoia in a way that you haven't before. It's expensive and you're starting to lose people that you said are very important to you. Tell me a little bit more about that. You see? So I end on that. So it gives a bridge to being able to talk more about it. We want to talk, that's change talk when they're talking about hating the negative impact of cannabis or any other substance or any other negative behavior that has changed, right? So you end on that. Amplify, you know, this is where you can, this is where you can sort of just take something that somebody is giving you and just add a little bit of extra emphasis to it and to see how they respond to it. They might say, you know, I've been having a little bit of problems with drinking. And we know that when somebody is disclosing that they're having a little bit of problems with drinking, that it's probably more than that. Right. And so we would say back to them and say, seeing that you're having a little bit of problems drinking, I suspect it might be more than a little, is that true? Or, you know, and you give them a chance to say, well, yeah, it's, it's, it's true. Yeah. I'm drinking every morning when I wake up and my bank account is at nothing. And all I'm worried about is how I'm going to get another bottle of wine. So you're, you're digging more into the change talk there. Strategies or changes of stage, stage four is action. So here is what I think most of you know very well, it's implementing change, knowing the resources, the referrals in your area, the monitoring that change with that individual. So I don't know what your contacts are with individuals, but maybe every day, maybe, maybe every week, maybe every month, but you want to check in on them. How's everything going? Okay. Okay. All right. Yeah. It's challenging. Yeah. Yeah. We talked about that. That's definitely to be expected, but I feel you it's really, really hard to make big changes like this, but that is normal for everyone. And the fact is, is like, you're doing it. Like, how do we keep this going? You know, how do I help you? What are other resources? Are you taking care of yourself? What are your values? What's most important to you? Like, how can we sort of like feed you? So we can, we can provide additional supports in your life while you're going through this really tough change of not using again. Right. So we want to reinforce that commitment and just say, you are a miracle. Like you're, you're doing great. Look at you. You look completely different than when you came in two months ago. I can't believe it. How do we keep this going? Right. It is, is action is this sort of action stage. And I have already gotten a little bit into the maintenance stage is this idea of like, how do we keep this going? But to get to the maintenance stage, you have to keep the action stage sustainable. Right. What if they're not doing great and a treatment center, is there another treatment center they can go to? What if they're not doing great in IOP? Is there a different level of treatment that they might be more appropriate for? Right. So really making sure during this action stage, we anticipate maybe some small problems, and then we pivot to make sure that the result isn't a return to use or a relapse. Preparation to action. We want to explore goals, clarify their goals, create that change plan. Sometimes we call this treatment planning in the treatment center environment. We want to elicit change strategies and have the importance of multiple options. And again, try not to have a cookie cutter approach to substance use disorder treatment, because for every individual in recovery, there's a little bit of a different recovery pathway. I think many of us could agree to. And we want to support those action steps. And again, just encourage them, help them to create rituals for leaving old behaviors behind. Use as always with motivational interviewing, reflective listening and affirmations. And then of course, is maintenance, right? They're doing the thing, they're succeeding. We want to keep them doing the thing. And we want to talk at that point about relapse prevention. How do we keep them from having a return to use? Creating those relapse prevention plans. How do we help them to cope with the stresses that are coming up? And we hit on some of that in the last slide, I skipped ahead. But the goals would be maintaining the new behaviors and positive changes there with everything that we've talked about. So we want their action plan to become habitual, right? It's a habit now. The new behavior must become integrated in the individual's lifestyle. But there's always the danger of reverting back to the previous pattern. And when the new behavior becomes fully maintained, or the new behavior becomes fully maintained only when there's little or no energy or effort to continue it. And the individual can terminate the cycle of change, right? And so we want to keep their motivation up by continuing to have those conversations. Because there's going to be some negative impacts of early recovery, right? They're going to be craving, there's a wide variety of things that they could be dealing with sleep issues. But we want the focus to be on the positive of recovery. So we want to be asking them questions in the maintenance phase, like, how has this changed your life for the positive? And then get them to dig deeper into that by using open-ended questions. Okay, tell me more about that. Okay, so it's impacted your family life. Incredibly, how has it impacted other parts of your life? How has it impacted your finances? And inevitably, it will have positively impacted their finances. And again, affirmations, we don't have to go through all of these, but understanding that these are some great affirmations to use. I appreciate your efforts, despite the comfort that you're at. Thank you for all your hard work today. You're determined to make changes and I can see it in you. And I just want to say, I see you, I see what you're doing. You're killing it. So respect and cultural responsiveness. I won't go through this completely. But this is just to say that being culturally responsive and respectful of all different pathways and diversities of individuals that we work with is crucial. And it's a big part of motivational interviewing. This is sort of repetitive. Integrating MI into client interactions. Again, yeah, we can close on these different bullet points, but engaging actively with the individual, focusing on the client's agenda and not our agenda, I think is probably a good sort of approach and thing to think about before you go into a conversation with someone. Be aware of the client state. And again, if we're just sort of processing folks into our programs in and out of them, we're not really taking the time to get to know the individual and how we can support them and serve them. Evoke intrinsic motivation. We want that motivation to come intrinsically from that person. What about that person does not want to live a life handcuffed by problematic substance use anymore? We want to evoke that from that person because they're bigger and better than that. Collaborative planning. When I start working with an individual, I say I am not the person with all the knowledge. I am your partner and I am here to work through this with you if you're here to work through this with me, right? And so it's got to be this collaborative planning process because when we start taking this more distant authoritarian approach, that's what gets people out of treatment settings. They're just like, I can't do that. I quit drugs and go through that? I don't think so. So it's got to be more of a collaboration. I think we're doing great work in the United States to get further in that direction. And then, of course, I've got a few references here. All of this comes from the Substance Abuse and Mental Health Services Administration, SAMHSA, a wonderful, wonderful body of research and just initiatives that you can tap into and learn more about a variety of different approaches to helping folks who are struggling with substance use. And, of course, DeClemente, Addiction and Change, how addictions develop and addictive people recover that sort of walked us through those different changes of stage. So, again, I thank you very much for letting me talk at you for an hour and a half. I wish I was right there with you. I've really enjoyed this series. I hope that you have gotten some knowledge and some pointers and some tips that have helped you evolve as somebody that's helping people, because it truly is noble work. And I thank you again. Hope you have a wonderful day.

motivational interviewing

Opioid Response Network

substance use disorders

empathy

trust building

behavior change

reflective listening

therapeutic alliance

intrinsic motivation

cultural responsiveness

SAMHSA