Welcome back, everyone. So today in Module 3 or Session 3, we're going to be talking about some skills related to communicating with people about substance use. So we're going to talk about examining bias around substance use, which is kind of an extension of what work we've done in the two prior sessions. And then we're going to have some communication skills regarding substance use, and then we're going to do some skills observation. You're going to watch us working through the items here. So I'm going to be pulling from motivational interviewing and looking at skill set. And motivational interviewing skills are particularly useful in communicating with people around substance use, mainly because it's possible to talk to someone and avoid persuading them without permission. Why that's important. When we persuade someone and we haven't given them permission, we are persuaded by someone and we haven't given permission, we tend to get defensive and we really are like, I don't want that. It doesn't feel good. It feels like someone's trying to sell us on something that we don't want. And it can almost feel like a sales tactic. Also connected to this too, and a lot of the folks that we're working with, most of the folks that we're working with are very much ashamed or embarrassed about their use or afraid that we're going to judge them for their use. Further, they're also likely ready to think of us as going to come in and tell them why their substance use is wrong or bad or some other going to be causing them a problem. So we're going to do a demonstration here in a moment. And I'm going to do an example of someone talking about something from their life that they want to change that they haven't changed yet. It's not going to be a substance use related thing. It's going to be an example here of just having this type of discussion, or well, actually specifically this first one is the type of discussion we don't want to have. And so for this one, I'm going to be persuading without permission. And so in a moment, I'll introduce the person here. They're going to be talking about the thing that they want to change, but they haven't changed yet. And they're going to go through for one minute and talk about how the thing that they want to change. They're going to describe what it is, why they need to change it, how they should change, what they've been thinking about changing, and what they have not changed yet. And then once that minute is complete, I'm going to take 30 seconds to sell the change. I'm going to go through this list here and explain why they should change. I'm going to do my best to give maybe two specific benefits of the change, tell them how they should do it, and also emphasize how important it is. So for this, let me introduce Sarah. Sarah's been so kind as to help us out here. And she's going to talk to me about something that she's thinking about changing. Hey, Sarah. Hi. Hey, are you ready to start? Yes. All right. We've got the minute clock going now. Okay. So I know that I need to start exercising more. I've had doctors tell me. I realize that I probably should be starting more. I sit a lot for work because I work at a desk job. So it's something that I know I need to do. I recently bought like one of those bike things you can stick under your desk to bike. But I can't do it while I'm actually working because my attention gets divided. So I have to set aside time to do it. And I just haven't found the perfect spot to set aside the time to do it. Sometimes I can do it in the morning, sometimes in the afternoon, sometimes I'm working straight through the day and I just don't find the time to do it. So I really am struggling to figure out how to actually make that work and like make it happen to actually do the thing that I know I should be doing. Great. There's the minute. So this exercise piece is so crucial. I mean, it really is the most important change for you right now. You know that it'll give you health benefits. It will help you have more energy. It's going to help you do the things that you want to do. It may even make being at work easier. It's really just a matter of figuring out how to find a space for that bike. I mean, just picking a corner and going with it is really probably the most likely thing that you need to do. And that is really going to help you get this going. Stopping for a moment. That's persuasion without permission. Probably some feelings there. Let's actually, Sarah, if you would be so kind as to debrief with me here. Let me pull the screen up because there's probably some feelings about this. Let's first go with you were the speaker here. What was it like? How was it to have me tell you how and why you should change? I mean, like I already said, you're just confirming things that I had already said, but like me. So there wasn't anything new. Yeah. Did it? I'm wondering, like, whether moving the needle towards like the change of exercise, did it do it? Did it move the needle towards or away? Did it do anything? It just like just reconfirmed that I knew I needed to do it and that I needed to just do it just in the same spot. It did. OK. I can tell me as the listener, this is not my normal way. It never feels good to do this. And it's like, oh, no, I'm losing because I'm telling you something you already know. And many times I mentioned here that didn't really move the needle. But I can share for many folks, there's these kinds of reactions. Does anything on this list match an experience you had just now, Sarah? I was annoyed. That's not. But I was annoyed. That's what. That's a really common response to this because you're not for most folks, they don't feel heard. It's like there's nothing new here or worse, I'm getting advice I didn't ask for. Now, this is subtle or this was a more extreme example of something that can come up when we're working with folks of something that's called the fixing tendency. And this is where us as helpers, we got into this work because we really want to give people a lot of tools and advice and things that will help them live better lives or live lives that they're more satisfied with. The problem is, is that when we come in with all these resources and all these other things that can commonly come in as a case manager, it can come across as this fixing tendency and folks will have these kinds of reactions. This applies to talking to folks about substance use because so often, again, I brought up earlier how we're talking with folks about something that they're ashamed of and we're also coming in as the professional. And so coming in as the professional, they're geared up to think that we're going to talk to them about why their substance use is wrong, how their substance use is unhealthy, why they need to stop using. And so automatically, even before we open our mouths, the fixing tendency comes into play because they're ready, they're on the defense. So what we need to do is try to counteract this. So I'm going to give an example here again with Sarah. We're going to talk about the same topic here in a moment. It's going to be different. We're going to talk about it, but ideally in a way that's going to not create the problems or the fixing tendency that we just saw. Are you ready, Sarah? So we're just going to talk for a few minutes here about it, but it's a regular conversation back and forth. Yeah. So you mentioned possibly wanting to exercise more. Can you tell me what makes that an important thing for you? What makes that something to do now? It's just that I've noticed that I'm so stationary. With my job, there are days where I'm sitting for like three or four hours straight and not moving. And I know that that's not super healthy. So I really kind of want to move more, just add movement into my day. And I thought the bike would be a good way to do it. Sure. So it's really how much you're sitting with work. It's kind of like, so it's really how much you're sitting with work. It's kind of gnawing at you. Like, I know this isn't good and there's bad things happening to my body because of this. And I don't want that to happen. And so that's really sparked this. I need to find a solution and biking is what you've chosen for you to biking. Um, because I tried to figure out what you could do at your desk. That was like, like, like I could like do it with work. Um, there's like the, there's like the, you know, the walking thing, but I was like, that feels dangerous to me. Um, and so I felt like a bike would be easier. This was originally thought to be incorporating in and solving kill two birds with one stone. So, so to speak of exercise while working. So it would be naturally built in, but it didn't quite work out. No, I mean, I've done it. There have been several days where I've done it. It's just that like, you know, I have a very crazy schedule. It changes every, every day. And so like having a set time doesn't seem to work. So it's just trying to figure out how to acknowledge that and like be flexible, I guess. They're pretty far down the line on this. I mean, you've actually tested things out. You've tried it and realized that the schedule you've got the bike you've got even tried using it at work, but you realize the schedule, it's not quite what you thought. And so now you've settled on this idea of finding time away from work to do it. And it's more of finding a time slot, not necessarily location. And you've ended up on maybe after work. What are your thoughts at this point? My thoughts are, is that I should probably have a lunch hour. And, and if I have a lunch hour, I can use, you know, part of my lunch hour time to actually do the exercise and then have lunch because, you know, I also have a very bad tendency not to take lunch because I'll work through the day. So if I like actually put something on my schedule that says like, Hey, you have to eat at this time, please don't schedule a meeting at this time. Right. Like, I think that would work. But I don't know. I haven't tried it yet. You like to, I see that you really like to create these creative solutions that solve multiple things at once and be really efficient. And it also strikes me that your time is something that's really important to you and valuable to you. And so, yeah, you want to find that solution that fits that. You also said of like taking, solving the lunch thing and making sure you have a lunch and then also kind of maybe even feeling better having exercise and then lunch because, yeah, either making different choices for lunch or at least just feeling okay with whatever you have for lunch too. So lots of things in there. So you've got the lunch hour thing. It sounds like that's the next one you want to try. Yeah. Where are you at and kind of organizing that and planning that? I'm actually, I'm actually in a good spot because it's the beginning of the month and I don't have as many meetings yet scheduled. So I actually have an opportunity to pick a time where I don't have anything scheduled and like blanket my months as like, you know, at one o'clock every day, I can have a lunch hour put in there or something. I am actually in a good place where I can do that. Yeah. One o'clock and just mapping it every Monday through Friday, all the way through the week. So it sounds like that's something you're about to do. I should. Yes. Okay. There's some hesitation though. Yeah. I just, you know, schedules change. They just change at the last minute. So I think, I think, I don't know. I'm a planner. So part of me is like, I got a plan for when the schedule changes. What do I actually do? Right. What's my backup plan to the plan? Because I'm weird and I know that. So you're very thorough, making sure that everything's covered, that all your bases are covered and that you can make the most efficient use of your time that comes through every single piece here. Okay. So yeah, it sounds like that's the next piece is figuring out like, is one o'clock work and how can I make that work and as many days as I can. So let me just kind of summarize, cause we're going to wrap up here in a moment. And so getting the exercise is really important to you. It's something that it, well, more importantly, that the feeling of your job has you sitting so much and you know that that's not having effects on you that you would like. And so you're wanting to figure out a way to counteract that and exercise is there. You've picked the bike because it's the safest option. It seems to make the most sense for you. It's really, you know, you've tested some different things. You know the schedule is kind of weird and doing it while working doesn't work, but you think that a lunchtime could work. And one o'clock seems like it's the time that the best one, though I know there's some things to kind of solve when one o'clock doesn't work, what to do or coming up with some alternatives. Once you have that, it sounds like you're ready to go. Yeah. Okay. All right. Any last thoughts before we wrap up? No, I should think about what my backup plan is and then do it. Sounds like a plan. Great. Thanks, Sarah. Thank you so much for talking to me about that. So different than last time. So let's roll into a debrief here. Kind of, how was this different from last time? You actually made me think about how to actually like implement the thing that I was thinking about. It wasn't just do it because it's the right thing to do, right? It was, you teased out things that, you know, made me think like I could actually do this. Yeah. So whereas last time it didn't bring anything new up, this time it made you think of things you hadn't thought of before. How about that needle towards making the change before it was stayed in place? Is it the same? Did it move one direction or the other? No, it moved. I'm probably gonna be able to figure out before the end of today. When I can make a lunch time, so. Good. Awesome. So it had a significant impact. Great. So, yeah, this was different for me in the sense that this is how I normally work with folks. And so it felt much more natural and it was much more engaging because it was fun to explore what you had thought about and where you were working with that and help you come to your own solution with it. And that's that part, you'll note, I didn't give any advice here at all. And so any idea really was yours, which is nice because that means that it's your idea, you're far more likely to actually take action with it. So this, yeah, again, bringing this back to talking with folks about substance use with it, what's nice with this too, is you can be really neutral in using this and not giving advice. You're not taking sides, which hopefully will give them build trust and in you that you're not gonna push, you're not gonna lecture them and that they can open up about both what they like about their substance use and what they don't like about their substance use. And you're not gonna jump on one side or the other. It's not like, oh, wow, there are things you don't like. Let's talk about that. No, it's fine. We can go back and forth. So this is where it's a helpful piece and just not giving advice or resources can be really helpful because it avoids that fixing tendency. So we've got, there can be a challenge with this of it's impossible never to give advice. In fact, as a case manager, your job is to give resources. A huge portion of your job is to give resources. And a lot of times we're gonna have or feel like one resource will be more useful than another. And that is giving advice or persuading. And so before I even dive into this model here, if you have a resource or something that you think would be a good idea, you can just be just transparent and say, I have this resource. I think it may be a good idea, but let's see what you think or you may not and that's okay. And that in and of itself makes it more likely that someone will take in the resource and talk about it. Cause they're not gonna feel the pressure. You'll have been transparent that, yeah, you believe in this, but you recognize that they may not use it. What I'm gonna present now is an alternative and a step-by-step setup that's on the screen here of how to go about providing information in a way that will come across as neutral and will not be read as persuasion or giving advice. And it will make it far more likely that people will take the information in that you're talking to them about. So it's ask, offer, ask. So the first ask, we're asking them what their existing knowledge is. So what do they know about the topic? Connected to that is how interested are they in receiving information? And you can ask something like on a scale of one to 10, how important is it that you make this change or that you do something here? And that can gauge the closer to 10, the more interested they are. Though just how they talk about the subject can also let you sometimes know that they have existing knowledge or that their, I'm sorry, their interest level is higher. If their interest level isn't particularly high, or isn't high at all, it's important to think about whether to move forward. I would give the advice of not moving forward for the fact that at that point, you know they're not interested. So the chances of them using the information is really low. Instead, what I'm gonna think about is, okay, is there another way we can talk about this topic that might increase their interest? Or is there something else we can talk about that they're more interested so then maybe later on we can come back to this after we've taken care of some things that are more important to them? So I find that those approaches are more person-centered because it really is focusing on what their need is and where they're at. If there is interest, you can ask for permission to provide information. And then you go to the offer. So offer one piece of information at a time. So information, a single piece of information generally fits into about one to two sentences. I know that seems small. The part is that, and it can make it seem like it's gonna be cumbersome or take a lot of time to provide information, especially if you have a list of things you need to go through. The advantage to it is that one piece of, one to two sentences is what people can absorb the best. You may add a connection here of, sorry, affirmation. So affirming would connecting how using this piece of information would help them with what they're thinking about or something that's important to them, a value or goal if you know those. And you can also put in autonomy support in here, reminding them that using the information is truly up to them. It's their choice and it's totally fine if they don't and it's great if they do. Or yeah, it's totally fine if they do. You see the next ask here is reactions. So reacting to that piece of information as well as additional steps. I'm sorry, additional questions. Now you'll notice there's a back and forth arrow. There's a two directional arrow or bi-directional arrow between the last ask and the offer. This is there for a couple of reasons. First and foremost, if you've got a list of information that you need to go through, like you're doing psychoeducation or multiple resources, you might provide one of the resources or one piece of the psychoeducation, see what their reaction is, provide the next piece, see what their reaction is, provide the next piece, see what the reaction is. And so that's a way of working through a list of information. The other is if you're generating a menu of options and having a discussion back and forth to help generate possible solutions, you may go back and forth between ask and offer. And then the last reason why you might do that is if there's a misunderstanding, you might go back and offer a different piece of information to try to clarify. Next steps is on here, but we really wanna make sure to only do that if there is commitment. So I'm gonna show you a quick video of an example of someone doing ask, offer, ask. It's about four or five minutes long and we're gonna go and he'll be starting it here. It's about smoking cessation aids. So it's definitely a somewhat different topic here, but he does walk through each of the steps in pretty good detail. And so that's why I wanna show it as an example and then we'll have a little bit of, I'll discuss a little bit more about it afterwards. So let me come out of this share and I need to pull up the video. And bear with me here just a second while I get this set up here. Of course my computer is taking a second to load. I'm almost there. Okay, let me get this shared properly, share my sound. Okay, here we go. Here is the video clip now. Where that leaves you now. Is there no sound? There is still no sound, oh-oh. I think it's happening. I hear sound. You do hear sound, okay. Well, that's the important part. Thank you. But with a surgeon or indeed in a situation like this. Yeah. Yeah? Yeah. I wonder where that leaves you now. Well, I'm here. So obviously I do wanna do something about it. What that is right now, I'm not sure. I know there are aids out there such as the patch. I've seen people wear the patch and they swear by it and they're almost proud of it. See, here's my patch. Yeah. Nicotine gum, all that good stuff. I was gonna ask you about that. I mean, how much do you know about those kind of stop smoking aids? Not much, not much. I've never really tried to approach quitting. Right, right. I didn't see the need, but. Right. And I mean, that'll be a decision that you take for yourself and I'm not suggesting you make that. But what is it that you'd most like to know about stop smoking aids? I mean, is there any piece of that puzzle that I can help you with? If I were to choose one, I definitely wanna know how the side effects are gonna affect me. Right, right. That's one thing I worry about with drugs that I see on TV, especially the new ones. The side effects are anything from sexual dysfunction to, you know, ulcers and so. And if you're gonna make a decision to stop smoking, you wanna make sure that you get an aid that's gonna suit you and is not gonna have side effects. Exactly, what's the point of quitting smoking if the thing that is helping you quit is messing you up? And perhaps I can just let you know that there is quite a range of these aids. Some of them you're quite right, like bupropion. That is a drug that can have side effects and it doesn't contain any nicotine, okay? So that's one kind of aid, okay? But then there are others that contain nicotine, like a patch or gum, that really are devices for helping you tail off the withdrawal symptoms gently. So there's broadly those two kinds of aids and the success rates of them are reasonably good. But it sounds like you're particularly concerned about a drug that might have side effects. That is my main concern. If I could take something that could help me quit, I could probably embrace that as long as it didn't affect me adversely because I have enough problems. Sure, so if you could avoid the side effects, you might even consider taking one of these supporting aids that didn't have side effects. I might give it a chance and also cost is a factor as well. If it's expensive to do, then I'm back where I started. Maybe my health will get better, but I'll still be... Exactly, because that was one of your concerns about the smoking. Absolutely, absolutely. So you might have to make some kind of financial sacrifice to quit smoking and you're concerned about that. Sure, but in the long run, I know, I'm probably just trying to enable myself. But yeah, I guess that my number one concern would be there's just the side effects. Right, right. Okay, let me see if I can just summarize what we've said so far because we're gonna be stopping the interview quite soon, okay? Okay. It's something that is important to you and you definitely get benefits from it. On the other hand, you've noticed its effect on your cardiovascular health with a history of heart disease. And if you could find some kind of support aid that didn't have side effects and wasn't too expensive, you might be prepared to go for it. I think I might be able to give it a try. You might even give it a try. Might even give it a try, yeah. Okay, there we go. Coming out of Cher. Let's see. Right to the slide. So we saw that example of Stephen who was the one providing the motivation. Oh, wait, let me actually switch something back so I've got it correctly. And that was Stephen and Barry. Barry was the one with the crutches and Stephen was the one doing the MI. So talking about how he did with this Ask, Offer, Ask. It started pretty much right away. He went in and talked to Barry about his existing knowledge about smoking cessation aids. Something that's in there was that Barry knew quite a bit about it. He knew a lot of information about the smoking cessation aids and that means that at least at some point, if not currently, there was a high level of interest. Barry, you could tell, had been thinking about quitting. It was on his mind. He was definitely ambivalent about it. And so that also was another piece that added to interest there. Now, Stephen did a couple of things to ask for permission. He asked, what ways can I be of most help, which is asking permission to be of assistance in some way and providing and they decided on providing information around smoking cessation aids. He also said when he started to provide information, he said, perhaps I can give you some information, which is another way of getting permission in a more subtle way. And this is really important because it's good to have multiple ways to obtain permission more than just, is it okay if I give you some information because it can get kind of annoying if you keep asking it the same way. So Barry did, he didn't say no. So it was kind of implied permission there. So Stephen moved ahead and offered information. You'll notice he didn't offer information one piece at a time. Normally, we wouldn't want to do this. The reason why I believe it was okay here was because Barry had a lot of prior knowledge. He knew a lot about the different smoking cessation aids and that's made it okay to give more than one piece of information at a time because Stephen wasn't likely giving him very much new information. He was just kind of filling in some previous information that Barry had and likely maybe even confirming some stuff that he already knew. And so it was okay to go through a couple of pieces because he went through the gum and the patch. And then he talked about Welby-Trimner, I forget the actual name of the medication. And so he went through those two types of there. He connected using this of how it might help him on the rugby field. And so that was there as the affirmation. And then also autonomy support. He kept saying, if you choose, if you choose, kind of reminding him that this is a choice and that the if adds in that he may choose to do nothing. And then reactions. We did get reactions there and it ended pretty quickly after the offer. They just kind of reflected back and forth. Barry kind of put some questions out into the air that he needed to find something that definitely wouldn't have side effects and that wouldn't put him in a worse place. Though we didn't go to next steps. This is likely due or we know it's due to the fact that Barry didn't have appeared to have very much commitment. So commitment language would be I'm going to do this. I will do this. Instead, we were hearing I might do this. I might make the select side. I might if I do do decide this. It was nothing was very nothing was firm. And so that it to have provided information or talked about next steps would likely have felt like pressure to Barry and would have likely shut him down. And so this is also that part similar to if there was no interest, we don't want to necessarily move forward if there's no commitment. We don't want to start talking about next steps or if there's very low commitment. Instead, we want to talk to them and see if there's ways that we can build commitment or give them time to build it for themselves. So that's an example of walking through ask, offer, ask. Now, an example, if you were to walk through, say, deciding whether or not to take methadone. So I would ask them, what is their existing knowledge of methadone? I'm listening very much for stigma language in there because it's so common with something like methadone. Like, oh, it's just these clinics that are in really bad parts of town. They're just criminals that go there. I'm just replacing one opiate for another opiate because I'm listening for those. Those are all examples of stigmatized stigma around methadone that I'm going to want to then potentially correct in the future. Of course, gauging their interest in finding a medication or potentially using something like methadone, getting permission to offer that. And I would provide an affirmation of how using methadone would likely, in certain cases, say this is someone that's a high opiate user, has a high opioid tolerance, and has had struggles with buprenorphine, having a smooth ride getting onto it. This is something that's going to be a smooth, likely be a smoother ride for you getting on board. And you're going to get to an effective dose probably in a much more comfortable way and likely more quickly as well. And that would be an affirmation. The information would be talking about methadone and what it does. And then like one piece of information would be methadone really is a medication meant to make you feel, not feel the withdrawals, but not make you feel high. If you so choose to take this or it is up to you what to take, I can't tell you what medication will work best for you. You have to choose which medication works for you or if any medication works for you. And that's the autonomy support. And then looking at their reactions, seeing if there's additional questions and possibly filling in the gap to fight stigma, like talking about how methadone is really meant to be a long acting opiate. And so you're not getting high, but you're preventing withdrawals and you're making it so that it's easier for you to go about your daily life and comfort so that you're going to be less likely wanting to use substances or other non-stigmatizing pieces as well. And then, again, if there's commitment to it, you feel it sounds like they're interested and they're looking for options or maybe even asking about next steps, then you can provide it. But otherwise, you would just stay put and let them kind of go with that. And so this wraps up portion three. So this is all the final portion of this. It's been pleasure working with you. Here is the QR code, just in case we're needing to do evaluations. And then we are wrapped up.

effective communication

substance use

motivational interviewing

Ask-Offer-Ask technique

smoking cessation

role-playing

building commitment