false
Catalog
Medical Student 8 Hour Buprenorphine Training
Session 7: Evidence-Based Counseling
Session 7: Evidence-Based Counseling
Back to course
[Please upgrade your browser to play this video content]
Video Transcription
Welcome back. And again, I'm Dr. Wyatt. In this module, we will review some of the key components of behavior, along with various evidence-based counseling and approaches to helping patients with substance use disorders through counseling. The tenant of this counseling is associated with motivational interviewing. We will review and explain the core principles of this therapeutic approach, and we'll review the fundamentals of screening, brief intervention, and referral to treatment. A widely accepted approach to identifying and helping patients with alcohol use disorders and, with less evidence, people with drug use disorders. So consider how counseling might be an important component of medication-assisted treatment. How do you feel that working on changing behavior might support the recovery? There is good evidence that medication for opiate use disorders on its own will result in improvement in behaviors associated with opiate use and move patients towards reduced drug use. However, in addition, there are some common and effectively used therapeutic techniques that can help engage patients in their recovery, including medication compliance. We spent a fair amount of time looking at the patient evaluation. You will remember that there are a variety of psychological and behavioral factors, along with social determinants associated with the initiation and continued use of alcohol and other drugs, in this case opioids. Consequently, it is important to help patients recognize that there are alternative behaviors which they can practice to move their lives in a more positive direction. This can include management of their environment to reduce the triggers associated with their continued use. Therapy can allow them to understand those triggers more clearly and be able to preempt the exposure to certain triggers before they stimulate cravings and drive them toward continued drug use or relapse. After a period of abstinence from opioids and other drugs, we can also help identify and address thoughts and behaviors that can contribute to an individual's experience of anxiety or depression. This is cognitive behavioral therapy, also known as CBT. The pharmacologic interventions for opiate use disorder are used for two different purposes. The first is to help the patient with what is often their most frequent immediate concern, the symptoms associated with withdrawal from opioids. They often think this is the primary driver of their continued use. The second is to reduce the biologic drive for continued drug use secondary to the effects on the limbic system in the brain associated with addiction. Essentially, the agonist medications buprenorphine and methadone can reduce the drive for drug use by satiating this drive, while naltrexone reduces cravings by its effect on endorphin release. So these medications reduce the drive and can then allow the patient to be more engaged in making the conscious behavioral changes associated with long-term recovery. Psychosocial treatment is introduced through communication involving the prefrontal cortex. One is conscious of this interaction. Therefore, they are able to develop an understanding of the disease and associated behaviors, potentially increasing their motivation for change. They can then make predetermined alterations in their environment and behavior, reducing the triggers to craving and subsequent drug use. Think about the statement, it is easier to avoid temptation than to resist it. Kind of like not putting an open cookie jar in front of a child and telling them not to reach in. Pharmacology interventions work in the limbic system of the brain and are associated with the needs and automatic behaviors, while psychotherapy is initiated in the prefrontal cortex and indirectly will affect unconscious behavior over time. Let's talk about the ABCs of behavior change, an acronym which can help us think about this issue. The letter A stands for antecedents, which happens before we are triggered to using a drug. These cues can come from people, places, and things which stimulate behavior. They can also come in the form of emotional stressors. In the recovery community, the triggers are often referred to as HALT or H-A-L-T, hungry, angry, lonely, tired. These are emotional triggers associated with returning to or continuing a drug use. Once we have begun to understand the antecedents, we can then look to the B, which stands for behaviors. In looking at behaviors, we're asking what was the cascade of events that took place following the antecedent that resulted in drug use. Once we understand that, we can consider what changes we might make in behavior when confronted with these same cues or stressors. This can then lead to consideration of the C for consequences. This is the idea of playing the scenario forward, as opposed to thinking only of the immediate consequences to not using the drug or just acting on automatic behavior associated with addiction. This results in a broader view of the consequences tied to the continued use of drugs. One needs to be able to have a moment to think ahead, change the antecedent environment in some way, have alternative behaviors well-practiced and available, and then, if challenged, be conscious enough to play the consequences forward. This is the ABCs of behavioral change. There are a few different evidence-based counseling approaches. We're going to review the more commonly established therapies and modalities that can be helpful in working with patients with substance use problems. They include cognitive behavioral therapies. This, again, is the development of different cognitive understandings of how certain feelings and environments can alter our behavior. Once this has been established, a person has a greater likelihood of being able to put in alternative behaviors in place of their drug use. Next, there is medication management, which is an important interaction between the provider and the patient. There is a therapeutic aspect to the meeting that takes place in this exchange. The provision of a substance for the patient to use and then following up on how their recovery is progressing involves the development of a relationship between the provider and the patient that can be enhanced through the development of better interpersonal interactions. If done correctly, this can be an important contributor to the patient's recovery. Mutual self-help groups are not typically thought of as therapy but are associated with the development of pro-social groups in which the patient can be involved. These groups can also help the patient reflect on their drug use and the effect they and their drug use has played in their relationships. Motivational interviewing is a process used to help a patient identify their own motivations for change and then helping to further enhance change. Let's look at these therapies a little closer. Cognitive behavioral therapy is based on social learning theories and principles of operant conditioning. It places emphasis on the functional analysis of drug use, the patient's understanding of their drug use within the context of the ABCs, antecedents, behaviors, and consequences. Skills training can be very helpful to the patient in recognizing feeling states and situations that resulted in their being more vulnerable to drug use. Once that has been established, then one can practice strategies to avoid those high-risk situations. Many of these triggers are very difficult to completely remove from one's life, so patients need to practice skills to cope effectively. This can result in their being more capable of remaining abstinent. Medication management typically lasts only 15 or 25 minutes on a weekly or monthly basis. During an individual session, self-reported use and stressors will be elicited and reviewed. Various lab markers can be obtained and reviewed with the patient. If the patient has used a drug, one might discuss various consequences to their use, both as the patient has experienced it and how treatment might be adjusted to help them abstain. So we are essentially monitoring their adherence to treatment, their response to treatment, and any adverse effects they may be having secondary to the medication. It's also important to ask about their daily habits in an attempt to address the development of healthier behaviors around diet, sleep, and exercise in achieving a better general health and a stronger recovery. We also continue to encourage the use of mutual self-help groups in their treatment. There are different types of mutual support groups. Alcoholics Anonymous is the oldest, having started in the 1930s. There are now a variety of anonymous types groups. They are based on the 12-step model of sobriety. This hinges on the understanding of there being a higher power that can help them in supporting their recovery. Some will use God as their higher power, but the higher power can be anything the patient feels is helpful in their recovery. These groups have a very strong focus on mutual support and building a network of individuals that are also struggling or have struggled with the disease of addiction. Patients with opiate use disorders can attend either Narcotics Anonymous meetings or Alcoholics Anonymous meetings. Some of these groups may reflect the use of medication for the treatment of substance use problems and patients are encouraged to find groups that are more accepting of the use of medication. However, the National Office of AA and NA have endorsed medication model as a tool to strengthen recovery along with social supports. Self-management and recovery training or smart recovery groups are based on more secular principles and use the stages of change associated with motivational interviewing and cognitive behavioral therapies as a tenant to the management of a person's recovery. This form of therapy has been recognized by the National Institute of Drug Abuse and the National Institute of Alcohol Abuse and Alcoholism as an evidence-based form of recovery management. Motivational interviewing is described as a collaborative conversation to strengthen the person's own motivation and commitment to change in the spirit of acceptance and compassion on the part of the interviewer. It utilizes a person-centered counseling style for addressing the common problems seen in patients surrounding ambivalence to change. Core aspects of the interviewing skills includes the acronym OARS, O-A-R-S, open-ended questions, affirming, reflecting, and lastly summarizing. The collaborative conversation remains goal-oriented with particular attention to the language the patient uses indicating their potential state of change. Motivational interviewing is designed to strengthen the person's motivation to commit to specific goals. This is done by eliciting and exploring the patient's own desire for change. To effectively establish true motivational interviewing, the interviewer needs to maintain an atmosphere of acceptance and compassion. The practical aspects of motivational interviewing require the interviewer to maintain and include such things as the need to remain open-minded. There are a variety of ways in which the patients can arrive at their goal and reasons why they are seeking it. The interviewer needs to build on these patient-centered ideas. This is done by listening, then asking, then potentially offering advice when it's appropriate. The listening starts with asking open-ended questions, allowing the patient to explain their reasoning. This is followed by the establishment of good interaction with the patient and developing greater clarification for the patient and the interviewer. At this point in the interview, it is important for the interviewer to be very concise and avoid wordiness. The patient should be saying many more words than the interviewer. Avoid interpreting the patient and instead allow them to fully describe their understanding of the problem and potential solutions. You want to enter into a relationship that is cooperative and not try to force change. Ultimately, using the patient as a consultant in finding their own solutions to the problem will be most helpful. To do this, the interviewer needs to remain open and empathic to the patient. There are four steps in the processes involved in motivational interviewing. The foundation of the interview is engaging the patient. During this stage, you will want to identify mutually agreed upon specific goals. Next, you want to focus the patient on their agenda. What is established as their goal. During this stage you can bring greater clarity to their goal utilizing motivational interviewing. Once they have established their goal, you can evoke reasons for change. Doing this you may also potentially strengthen their resolve for change. Lastly, we want to help establish a plan for obtaining these achievable goals. This will include how they will do this over time. By the end of the interview you want them to have strengthened their consideration for change and have experienced positive feelings evoked from the idea of change. We'll now look at some of the questions one could ask oneself in establishing these different processes of motivational interviewing. The foundation again is engaging the patient. In this stage you could ask yourself things like, how comfortable is this patient in speaking with me? Is there some adjustment I can make in my questioning, my positioning myself, or my facial signals that could help the patient be more comfortable? How supportive and helpful am I being? This often has to do with how closely am I listening to what they are saying and picking up on their goals instead of rushing to help. Do I understand the person's perspective and concerns? Empathy is the most important consideration in this. What would it be like to be in this person's place, considering the experiences that have been elicited, and am I having trouble getting there? Do I need to go back and help establish greater clarity? This may also help the patient in clarifying their own personal goals. How comfortable do I feel in this conversation? Again, have I allowed the person to be comfortable with me so that there is an easy flow in the conversation? Does this feel like a collaborative partnership? This is paramount in good motivational interviewing. You want the patient to be able to describe honestly to you the stress they are experiencing surrounding the reason they have come into this interview process. With that, you can establish more clearly a patient-centered collaborative partnership in helping them reach their goal. Next is focusing. Focusing revolves around the interviewer's ability to keep the patient's goals for change at the center of the interaction. We need to be questioning ourselves at times whether our aspirations for the patient are different from theirs. By doing this, we'll be able to be more capable of working with a patient in reaching their goals. This is done in part by establishing a very clear sense of where the two of you are going together to reach their goal. This should feel more like a dance than a wrestling match. If you feel some sense of discord, do not immediately jump to it being the patient's resistance. First, check your own presence in the therapeutic relationship. Remember, you can only change your own behavior in a relationship. However, if that change is effective in what we are trying to do here, it will very likely result in changes in the patient's level of comfort and behavior. Then, you can start to dance. Think of this as a challenge for yourself. Remember, there is a place in everyone that is seeking to be heard and feel they are understood. Can you find that place in the patient sitting in front of you? Often, it means focusing. Various responses are important in maintaining consistent motivational interviewing. Whenever you are thinking of moving the interview in a slightly different direction or attempting to start a motivational interview around a specific subject, it's important to ask permission to move in that direction. It is inconsistent with motivational interviewing to start to give advice or information concerning change without the patient's permission. When you start to give information or advice following the asking of permission, you want that advice to affirm their strengths and then support them in how they might attain their goals. It is inconsistent with motivational interviewing to confront the person with disagreement in a variety of more confrontational ways. You want to emphasize their freedom of choice and autonomy. You want them to understand that they have the ability to take control. This is the most effective way they will achieve their goals. Don't challenge the person's autonomy by giving orders or commands. This will set them up potentially for discord or disagreement. It will potentially start them down the road of negative belief in their trust of you and their ability to attain their goal. Now we are at the stage in this process where we attempt to evoke the patient's reasons for change. During this process, we also want to identify the patient's reluctance in their confidence to establish their desired goal. It is at this point you start listening closely for change talk. By listening closely, you begin to understand and ask, am I looking too far ahead of the patient or moving too fast in a particular direction? Is the patient still in a state of ambivalence or am I hearing change talk associated with direct action? There is an entity known as the writing reflex, which means you are hearing things that you want to change in the patient and reflexively start pushing forward, but then start feeling resistance. This is an indication you are moving too quickly. You may see this as resistance on their part, but it's important that you remain aware that you may be creating this resistance by pushing the patient in an uncomfortable direction. They may start to bring up ideas of why they are not ready to change. They may be stimulated to consider the positive aspects of where they are in their continued drug use. This may include difficulties they feel in being capable to overcome their use of opioids and their confidence to make change. This is not the direction you want to move the patient. You want to try to help them move away from these ideas, but this will only come when they are fully engaged in the commitment to change. Your role is to support the person in making positive change. These are changes they choose for themselves and will commit to. There are types of change talk you can train yourself to listen for. You can help a person prepare to change, and you can help them mobilize toward change based on the questions you ask them. As a person makes statements on behalf of one position or another, he or she becomes more committed. We talk ourselves into and out of things. This is change talk. Sustained talk is what we attempt to evoke during a counseling session. This slide gives you some examples of questions soliciting change talk. On the left are the expressions the patient might address in considering change. There are questions that can help move the patient towards describing their status within each of these expressions. On the right, you see if these are preparatory questions associated with evoking preparation for change or mobilizing questions that evoke action associated with change. When asking what would the patient like to be different or asking about their feelings around a difference in their life, you are preparing the patient by exploring their desire and ability to change. In this case, building a life without opioids. Then ask, so what do you think you will do? This can evoke commitment and elicits mobilizing change talk by them getting to their own strengths, those they could utilize in reaching their goal. You can also try to engage them in identifying and focusing on the reasons they want to make this change. This should add more depth to their desire. Then lastly, in preparation, we try to strengthen their resolve through their greater understanding of the importance of making this change. Here you are evoking their need to make change. This touches on the emotional charge behind making this change. Once they have started change talk, indicating they're starting to mobilize, you will want to attempt to elicit statements associated with their commitment to this change. What is their willingness to take specific steps towards change? Lastly, you're setting them up to start mobilizing a plan to establish change. This can be evoked by questions such as what steps have you already taken and what actions are you going to take next? Now we get into the planning stage. Ask yourself about the patient. What would be a reasonable next step towards change? What would help this patient move forward towards their goal? Am I remembering to evoke rather than prescribe a plan? In other words, is the patient at the center in establishing their plan? Did I ask permission prior to offering information or advice? In working with this patient, am I able to retain a sense of quiet curiosity and ask myself what would work best in working with this particular patient? These questions will help to keep the patient in the center of the planning process and potentially increase their competence in reaching their goal and your role in helping them. You need to be aware of ambivalence the patient may experience. Human beings are creatures of habit. Making change is difficult. These ambivalences need to be explored and not confronted. One can simultaneously have conflicting motivations. Contemplating change involves self-talk. This is associated with thinking through the pros and cons of various alternatives. It is the interviewer's role to identify the pros and cons and help the patient strengthen those ideals while at the same time exploring the suffering and difficulties associated with the cons. The United States Preventative Services Task Force has recommended that all adults in primary care be screened for unhealthy alcohol use and if a person has been identified as an unhealthy drinker, they would receive a brief counseling intervention designed on the principles of motivational interviewing. Brief intervention is directed at harm reduction, which emphasizes reduction in use rather than abstinence. This is an initial way to first engage a patient in exploring the potential of a smaller change in behavior. These interventions are time-limited, usually five to twenty minutes and client-centered, designed to reduce substance use. Because these interviews are not associated with a stage of change, they can be used in pre-contemplative patients. Typically, the interviewer is a health care professional and if performed in multiple sessions will be more effective. These assessments are organized around the five A's, ask, advise, assess, assist, and arrange. First, ask questions screening for the level of risk. This can include a screening questionnaire, lab values, or physical findings. Then advise the patient of the health consequences of their current use, including the review of lab values or screening results. In conveying the advice, you want to use strong, clear, and personalized language. Next, assess the person's willingness to change their behavior. If they're not ready for change, restate your concern. You can encourage the patient to reflect on the perceived benefits of continued use compared to decreasing or stopping and exploring barriers to change. This is where the readiness ruler, marked 0 to 10, can be used to have the patient place their readiness to change. On the ruler, 0 is not ready at all and 10 indicates fully engaged in making change. Most patients will not place themselves at 0. They will typically have some reason to want to change. So if they say 3, instead of asking what will it take to get you to a 10, you ask why not a 0. This will elicit talk about the reasons for change. You get them to voice their concerns, adding greater awareness and salience to the idea of change. Let them know you are willing to support them in the future if they are ready for that change. If the patient is agreeable to working on change, assist them by helping them develop a treatment plan in accordance with their goals. Start with small, achievable steps and be clear and concrete in explaining the specific plan. Lastly, always arrange a follow-up visit or specific referral. If possible, give the patient educational materials to review. There is strong evidence that individuals who stop or reduce their drug use have a lower risk of negative health consequences. However, there is insufficient evidence of harm reduction associated with either screening for illicit drug use or behavioral interventions used in the treatment of individuals with substance use disorders other than alcohol. At the same time, screening for these problems allows the patient the opportunity to contemplate making healthy changes in their life.
Video Summary
In this video, Dr. Wyatt discusses behavior change and evidence-based counseling approaches for patients with substance use disorders. He introduces motivational interviewing as the foundation of counseling, which focuses on helping patients identify their motivations for change. Dr. Wyatt also discusses the importance of screening, brief intervention, and referral to treatment in identifying and helping patients with alcohol and drug use disorders. He explains the role of medication-assisted treatment in reducing cravings and engaging patients in behavioral changes. Cognitive behavioral therapy is highlighted as an effective therapeutic approach, along with medication management and self-help groups in supporting recovery. The video also covers the principles and techniques of motivational interviewing, including open-ended questions, affirming, reflecting, and summarizing. The ABCs of behavior change (antecedents, behaviors, consequences) are discussed, along with the importance of evoking change talk and helping patients develop a plan for achieving their goals. The video concludes with a discussion on brief intervention and the importance of screening for substance use disorders to facilitate healthy changes in patients' lives. No specific credits are provided.
Keywords
behavior change
evidence-based counseling
substance use disorders
motivational interviewing
screening
brief intervention
The content on this site is intended solely to inform and educate medical professionals. This site shall not be used for medical advice and is not a substitute for the advice or treatment of a qualified medical professional.
Funding for this initiative was made possible by cooperative agreement no. 1H79TI086770 and grant no. 1H79TI085588 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.
PCSS-MOUD
PCSS-MOUD.org
pcss@aaap.org
8-Hour DEA Training Inquiries, email
PCSS-MOUD
.
ORN
opioidresponsenetwork.org
×
Please select your language
1
English