Hello, everyone. I would like to welcome you to this educational endeavor. My name is Dr. Al Rundio, and I am the PI on a grant that we have with the American Academy of Addiction Psychiatry. They are funded by SAMHSA on a grant called PCSS, which is Providers Clinical Support System for Medication Assisted Treatment. For the last several years, we've been educating people about the opioid epidemic and, of course, MAT therapy. And I'm really pleased today to introduce Dr. Angela Calistra, who is a professor at Drexel University in the Department of Counseling and Family Therapy. I've had the pleasure to listen to her presentations as well as present with her, and she's absolutely excellent at what she does, and she's a true asset to our university. Angela, if you could let me show the next slide. And I'm going to let her tell you more about herself when she starts. So Dr. Calistra has nothing, no conflicts of interest. And the overarching goal of PCSS is to train a diverse range of health care professionals in the safe and effective prescribing of opioid medications for the treatment of pain, as well as the treatment of substance use disorders, particularly opioid use disorders, with medication assisted treatments. Now throughout the webinar, you will be able to post questions in the box. And then Dr. Calistra will present, and we will allow probably around 15 minutes or so for questions at the end, and we will try to answer all of the questions. So with that, I'm going to turn it over to Dr. Angela Calistra. I think we're very fortunate to have her today. She'll do a great presentation. Thank you for having me. It's a pleasure to be here. Like Dr. Rundio mentioned, I am an assistant professor at Drexel University in the Department of Counseling and Family Therapy. I have been providing behavioral health services for the past 19 years, and I've been involved in medicated assisted treatment as a behavioral health and an addictions expert since 2003. I'm a licensed professional counselor and advanced alcohol and drug abuse counselor. My research is focused on opioid intervention and prevention, opioid overdose intervention and prevention. And I, for the past year and a half, have been working with a national model, Project ECHO, to train the interdisciplinary workforce on the integration of addiction and behavioral health care, working in the fundamentals of addictions medicine with MDs, DOs, NPs, and physician's assistants to get the addiction training necessary to carry out their patient cases. So it's a pleasure today to be talking with you about motivational enhancement techniques, the foundation of my work as a behavioral health and addictions provider. When working with patients with substance use disorder or high-risk behavior, I think nurses are really at the forefront of this work, keeping in mind that often in the health care system, you all spend the most time with the patient, so making sure that you have the skills necessary to tend to the addiction and behavioral health needs as they fit within your scope of practice. So at the conclusion of this activity, participants should be able to discuss and apply the basic principles of motivational enhancement techniques, such as expressing empathy, developing discrepancies, rolling with resistance, and supporting self-efficacy. We're going to review some styles and traps of motivational enhancement techniques. Some of the common, when I talk about traps, pitfalls that providers make when working with patients with addictions or behavioral health issues, and how to recognize and avoid falling into the common practitioner traps with patients, and then just spend a little bit of time talking about how realistic is the integration of these skills into primary care practice. I recognize that as a behavioral health provider, that often I have more time than primary care providers in health care settings have with patients. So what parts of these skills can you take with you in your job role, and what maybe would be best left for the behavioral health provider on your team? So we'll take a deep dive in that, and your perspective is really what I'll be focused on. I'll share a little bit of research that's been done in this space. See if I can get my slide to go next. Okay. So when we're thinking about enhancing patient motivation, I think to ground in this philosophy, we need to kind of think that this is not a technique as much as it is a style of engaging with the patient, or a counseling approach. And you might be saying, well, I'm not a counselor, but I would maybe argue that you maybe find yourself in a number of clinical exchanges with your patients. So think about the style of being with patients as a facilitative way of being with people. And it can be as useful in interpersonal interactions as counseling interactions. It's Rogers with a twist. So if you know anything about person-centered work, which is all of the reflective listening skills and setting up a clinical environment, it's kind of Rogers with a twist. You know, and if you think about, like, attending to the patient's behavioral health needs, there's many ways to get from here to there. But irrespective of which road is taken, you know, safe driving is safe driving. So this is a safe way to be with patients that are managing addiction and behavioral health needs. And it's a style of being with somebody. So essentially, these skills are designed to explore and reduce what we're talking about is natural ambivalence. The patients want to change very strongly, and they very strongly don't want to change. So how do we pull up a chair next to that ambivalence when the change is so necessary for their survival at times? Sometimes as providers, it's hard to digest them not wanting to change as well when their survival depends on their change. So the skills are designed to help you pull up a chair next to that. It's just based in this realization that ambivalence and resistance are natural parts of early change, that if we really take a deep dive, even into ourself and our own changes that maybe we've made around weight loss or the relational changes, that it often comes with this ambivalent state, if it's something that we've been doing for a while of wanting to and not wanting to. But the techniques are designed to enhance self-motivation. So it's not as much important that the provider knows that they want to change that they need to change as it is that the patient is aware that change is necessary. And so these skills are going to help us kind of pull that narrative from the patient. In order to do that, the provider must collaborate with the patient. So this isn't a top-down approach. It's not the provider telling the patient, this is what you need to do. This is what your diagnosis is, and this is how you'll get help by going to AA or going to self-help meetings, getting on medication. It's important that they realize that and tell you that. So it's relating in a non-judgmental, collaborative manner. It's a brief intervention, and it's something done with the client, not to the client. Clients' experience and their personal perspective provides a context that we can help them use to facilitate their change process. It's not a coercion, like you have to, you must, I'm sending you to detox while the patient's saying, I'm not interested in going through detox, but I am interested in stopping these withdrawals. So pulling on that narrative, collaborating with that narrative, and not coercing them to make a change that maybe they're not ready to do or not interested in doing, and it's about collaborating so we can move patients along a continuum of care when we're thinking about opioid use disorder. The other thing about the style is it's evocative. You know, in how we use the skills and facilitate the style, it's evocative. So our tone is really important, asking questions like, what do you think of this? What do you make of that? It's not, this is what you should know, I'm the expert. Everything about the model is very evocative, and it draws the patient out. It's uncovering hidden motivations and drawing out how change will ultimately become the client's idea. I think clients are always more willing to share their story with someone who listens and does not judge them, and then report their business to someone seen as looking for evidence to support a diagnosis. So when we're thinking about engaging with someone to increase their motivation to change, we really have to take a different approach to that engagement. It's really about collaborating, evoking their story and their narrative, and giving them the autonomy that change is entirely the client's responsibility, that these are the things that the provider can put in place, or that the provider can provide, like medication, buprenorphine, Vivitrol, methadone, but it's the client's responsibility and their autonomy is respected. It creates this safe and sheltered place for the client to step back, look at the big picture, and consider the cost and benefit ratio, because we're helping them see that in a very non-judgmental way. But again, rule number one, there's no in-your-face confrontations. If you feel like you're splitting hairs with the patient, you've kind of fallen out of your MI stance. And rule number two is we have to accept the client where they are. And I understand that when patients have high-risk using behaviors or substance use disorder, that that is a very challenging place to accept the client's choice and behaviors. But at that point, we can engage around harm reduction engagement, like what can we do to keep you safe if these are your choices in your high-risk use or the continuation of your substance use disorder, right? So there's lots of places along the continuum of care that we can continue to help them make autonomous and safe decisions as they move towards their recovery. And so we demonstrate autonomy with our skills by asking permission before suggesting options. So that might look like something like, given our conversation to date, I have several options you may find interesting. May I share some of them with you? And at that point, we may share about education around methadone, buprenorphine, Vivitrol, what these drugs are, how they can help them on their recovery journey, or thus help them stop experiencing the withdrawals, right? But we don't just give it. We ask permission to do that, to give those suggestions. Or we might say, others with whom I have worked with have told me of things they have tried, some of which you may find interesting. So remember, we're trying to be evocative, right? And we're trying to allow them the autonomy to continue or not to continue. And this has shown to decrease the client's resistance and be more open to the change process. But if you ask for permission, again, we have to be prepared as providers to what the client may say in response, and sometimes that answer is no. So at that point, that we're learning how to roll with the resistance and kind of not duke it out, right? We're not putting our boxing gloves on and fighting out the resistance that they may be putting up. We're using the resistance as a sign that maybe the provider is not using the facilitative or collaborative style, but instead taking a top-down approach. And I know in a medical model, it's almost like unlearning some ways of being with patients that maybe you're in ways that you're with patients in other ways around other medical concerns. But what we know about addiction is that this way of being with people actually increases their motivation to change as opposed to decreasing it. And so there's been clear data to support this, not only with alcohol use disorder and opioid use disorder and tobacco sensation, but also with other medical conditions such as diabetes and health regimen changes. So client resists change, and this is what we know is that this is especially pretty normal in the early stages of readiness. Opposing resistance generally reinforces it, so we want to do the exact opposite. So we're going to roll with it, flow with it, and understand that reluctance to and ambivalence about change are natural. So we're looking for this like Goldilocks zone in this motivational enhancement place, which is in between directing and following. So we're not going to do much directing, we're not going to do much following, but we're guiding. We're intentionally guiding patients towards evidence-based protocols that we know support their recovery efforts from opioid use disorder. And currently the gold standard of care for many people along the opioid use disorder continuum is buprenorphine for people that need more wraparound services, and the opioid treatment center methadone, and for others along a different continuum incarceration or that maybe have other restrictions placed on them, it may be Vivitrol. And that actually provides medicated-assisted recovery options for somebody with an opioid use disorder. So we're acting on resistance. The interviewer does not impose new views or goals, instead they invite different interpretations of existing facts. So you see the resistance, and I'm going to give you some examples of what resistance looks like from our patients, but you help try to reshape what's happening in the conversation. And essentially when we act on that in a motivational enhancement way, it'll facilitate ways for the client to consider new information, and it'll encourage new perspectives on old facts. If I can appreciate that resistance is more about my counseling intervention, my facilitative intervention, than about the client's willingness to cooperate, then it's easier for me to kind of stop and reevaluate my strategy, regroup and reframe, and then proceed with the client in a new way, as opposed to putting on my boxing gloves and going into the match with the patient with a substance use disorder and trying to prove to them that they are sick, they're on the path to very high-risk outcomes such as overdose or death, and I am going to do all that I can do to shut this down. Instead of taking that approach, if I can reframe that and know that these skills will actually counter that in more ways than putting on my boxing gloves. So these are ways that we're going to act on resistance. Often that we see providers fall into these traps that prevent motivational enhancement from happening. Some of the traps are just, you know, we've all done them. They're easy to fall into. So one of the traps, this is like a classic clinical, when we're treating clinical providers, behavioral health providers, one of the classic traps is this question and answer trap. And I think we, behavioral health providers do this because there's a nervousness about what to say or what to do next. And it's kind of like a default is this barrage of closed-ended questions, just like one question after the other. Now, this trap is not so much set by the client's denial as by the clinical person's propensity to employ what we call the writing reflex. It's just like the need to make this right. It's their reflex. It's their job. And so it's just like, I need to get to the bottom of this as quickly as I can. And so one of the rules to this when we're training behavioral health providers is to never ask outside of an assessment and screening. I mean, that's separate. But when you're facilitating this clinical engagement process with the patient, that we're never going to ask more than two closed-ended questions in a row ever. And that it's very rare that I'm going to follow a question with another question. And that motivational interviewing gives us skills of open-ended questions and affirmations and reflective listening and summaries. And that we need to use those skills to engage and evoke the client's narrative more so than just this barrage of questions. The other trap is that often we fall on is this labeling trap, right? So it's diagnostic and this like other labels. When we're engaging with somebody to make decisions about changing their substance use disorder or their high-risk use, when they're processing, I want to and I don't want to, when they're kind of within that conversation with us. The labeling trap, there's no reason to use such labels as positive change is not dependent on them. If a client wants to know, what do I have? We might suggest, you know, labels aren't important. You know, let's talk more about this change you want to make. And there is a time and place to do that in the diagnostics, interviewing and screening and assessment. But at some point, that labeling isn't shown to increase somebody's motivation towards behavior change. We also need to avoid stigmatizing jargon such as alcoholic, addict, substance abuser and instead see the person first, the person with a substance use disorder as opposed to the alcoholic. I think this trap results from treating the problem or the diagnosis rather than the individual with the problem or diagnosis. So when we're engaged in those conversations, we really need to avoid that trap. The premature focus trap, and I think as providers, we're limited in our time and our engagement. And maybe we have a lot of other clients and people needing things from us. So it's like we want to just get to the point. But sometimes that kind of results in us insisting on discussing your conception of the problem as the provider sees it, right? Especially when the client maybe has other concerns. And my take on that is sometimes you have to give the client or the patient what they want to have the chance to provide what is needed. Clients become defensive when they have to struggle to be heard or understood. And in this space of substance use disorder and high risk use, there's a lot of shame and guilt that comes with it. Even my patients that I've sat with for the past 19 years, even the ones that were as entangled in their severe high use disorder, opiate use disorder, as any of them would tell me, every single day they woke up wishing it would stop but continuing on with the chaotic decisions that they would make that was driven by their body's need for survival which was dependent based on what their brain was telling them for this drug. And so they would do anything at all costs but yet every day they wish that insanity would stop. So it's extremely important to not focus too quickly like they're still testing you out like are you safe. We still live in a world where addiction and substance use disorder and high-risk use is still highly stigmatizing and that it isn't always they're not always ready to do that because there is a lot of fear and what may result in it. The taking sides trap when the counselor detects a problem and starts to tell the client about how serious it is and what to do about it. So this could facilitate some argumentive behavior and you may start arguing with the client based on your view and essentially the wedge gets driven further between you and the patient. So at from a behavioral health standpoint and I can see why this maybe doesn't fit in primary care but for behavioral health providers we're neither for nor against anything or anyone. So we like to stay neutral to facilitate but we facilitate a path forward towards recovery efforts towards behavioral health recovery as well. And so we effective counselors essentially facilitate this process where the patient we can create an environment where our patients can look at it from all sides and then in an unconditional environment conduct a cost-benefit analysis and then make decisions for their mental health and their addiction health moving forward. And sometimes those are decisions based on harm reduction strategies and sometimes it's medicated assisted treatment and sometimes it's the integration of behavioral health care and sometimes it's all three wrapped in one right. Somebody may be taking medication for the opioid use disorder and then but he has moved on to methamphetamines it may be taking on a harm reduction approach as they try to get a handle on this new addiction that's filed up while simultaneously treating their behavioral health needs right. But we provide a space for them to do this where they can look at all sides of it and then make decisions moving forward. And so we're facilitating that process. The blaming trap which is historically kind of how we viewed the patient or the client's denial. Essentially confronting or blaming as denial alienates the client that kind of sabotages consideration of change talk. So what we want to do is diffuse blame instead of confront it. Dismiss blaming as unnecessary and that there's no need to label and move into this reflective listening stance. Who is to blame is less important than the concerns are about the situation in which if any options you are open to considering. Blame is essentially focused on the past and the present and there's little opportunity to affect their future decision-making for their substance use disorders or the high-risk behavior. So if we spend all of this time talking about you know their resistance or blaming them for things and we're not able to move forward and focus on the future of their recovery efforts. The expert track if you imply you have all the answers and you're kind of kind of lecturing and telling the client all the time the client then will have a risk of becoming passive. Sometimes the client can set this up and to add in a way to control the session and to focus less on them and especially my patients with substance use disorder they would do what do you think what do you you know and they would set it up so the behavioral health provider the addictions clinician would become the expert so they can do less work and processing in the space. But in this process the client really is the expert on themselves on their situation on their values on their goals on their concerns on their skill sets to move forward what's happened what's helped them in the past what hasn't and so we need to set up an environment where we can engage with those stories. You know when we think about facilitating a process to enhance motivation for change it's about collaborating and providing patients with a chance to explore and resolve their ambivalence around their use disorders or around their high-risk behaviors and then make decisions because they see that narrative so clearly to move towards their recovery path and if SAMHSA defines recovery this working definition of living a life of health wellness and purpose-driven life right so people can live that life as maybe they move towards recovery maybe that's abstinence only maybe that's medicated assisted recovery or maybe that's moving from a use disorder into high-risk use and having a natural recovery process that we have to remember that there's multiple ways to the top of this mountain and there's multiple tools available to keep people safe as they move towards their recovery. So let's just look at some of the ways that these traps play out so let's see can I'm hoping I'm I don't know if people can chat or talk but I'm going to describe a scenario and if you can tell me what trap maybe you see in the scenario that the providers engaging in and or maybe there's more than one so here's the first scenario. The patient has been in suboxone treatment for one year and has been doing well with all negative urine drug screens and a recent return to full employment. She recently missed her appointment and at her next appointment she reported experiencing withdrawals of hot and cold sweats and body aches. She was given a urine drug test and when it returned it was positive for methamphetamines. When the nurse asked to discuss the UA the patient stated it was inaccurate it wasn't true. The nurse stated that she was lying and it was not surprising that she would be lying since she is an addict. What trap do you see what trap or traps are happening here? I can't see the chat I don't know if people can unmute or share in the chat. Yeah I am muted I'm just reading in the question box I don't see anything. Let me see if the chat box I don't see anything either right now. Okay so when we get to the bottom part of this when the nurse asked to discuss the UA with the patient the patient stated it was inaccurate. The nurse stated that she was lying it was not surprising that she would be lying since she is an addict. Now maybe the nurse said this directly to the patient maybe she said this you know in in a place where the patient can hear it to her colleague right. We might see a lot of things happening here so calling somebody an addict is a labeling labeling trap and sometimes when patients you your analysis come back urine drug screens come back and they're positive that sometimes they're not ready to talk about it and sometimes they they do make false statements about the urinalysis and I that can happen for a number of reasons that for some of our patients there is a lot there's a lot on the line if they if for some they may lose their kids again they may go back to jail again that's being reported to the probation officer and systems aren't set up to acknowledge that opioid use disorder and like many addictions is a relapsing disorder and that one slip one setback is not a failure and so they're not a lot of systems even though we're making progress aren't set up or designed to see it like that and so one setback can often result in the loss of many things so as providers I think it's really important to not if somebody isn't ready to talk about it you can say okay here's the results take a look at it but at some point we need to sit down and talk about this for your recovery efforts and what I have found with that approach is that clients often come back through my door and say okay I'm ready so if I allow them the autonomy to have that discussion on their own terms as opposed to this isn't surprising you're lying to get what's going on you're putting you know this very labeling taking sides trap there there they react they become very reactive scared and fearful and sometimes react in ways that maybe go against our recovery efforts okay here's the next case the patient is on medication lower tab for back pain he has been taking lower tab for five years for his back injury that he suffered as a result of a war injury five years ago back surgery is an option but he has not undergone the surgery out of fear he takes the medication as prescribed two to three times per day his doctor has recommended he undergo the surgery and get off his long-term pain medication regimen as a result of his request John has been reporting more back pain and last month he ran out of his medication one week earlier the doctor tells John that he needs to come off the medication and go for the back surgery and he feels that he is being resistant so when we think about the traps here premature focus labeling trap expert trap and the blaming trap I think we can begin to see with these cases how sometimes things are going against each other so often you know with people with pain and possibly substance use disorder or people's fear of substance use disorder as providers that we can maybe move in ways that create resistance in our clients so maybe some of the traps that are happening here is this blaming trap which has been historically viewed as denial and confronting blaming as denial kind of alienates the client is sabotages their consideration for change talk so when the doctor says oh whoa you know you need to come off this medication you're being resistant here and the idea is to kind of diffuse that and say what's going on you've been taking this medication you know as prescribed for many years now and I know as a result of talking about back surgery there's been you know a change in your pain in your patterns of taking your medication can we talk more about that what do you make of that instead of telling him what the problem is and what we need to be be doing so that kind of moves into how do we gate how do we give our patients feedback and I think that's a very important tool because as health care professionals you are giving medical feedback to your patients and so providing feedback or providing clients with an outsider's perspective on what the client has said or done it's kind of like a staple of all behavioral health as well effective counselors it when I do this really know how to hold up the mirror for the clients to view themselves in like another perspective and ultimately as behavioral health providers that's that's our goal so with that said providing feedback is neither the counselors right nor litigation so providing feedback is the staple of motivational enhancement and in MI this is a low-key thing to do and it's expected that clients may be resistant the idea is that we're going to avoid arguments and present a warm sheltered accepting environment to do this and it's this kind of non-judgmental collaborative approach and in order to provide feedback we had to have listened to the client first we need to have pulled their narrative so once we know that we've done that and maybe it's time to engage in a feedback process this happens in a very intentional manner to keep resistance low so we might we always have to ask for permission I think this is like rule number one of the major rules and motivational enhancement techniques is always asking the client for permission respecting their autonomy to engage in that conversation so we might say a couple of things occur to me as I listen to your view on this do you mind if I provide some feedback always be prepared for the client to say no nothing will sabotage the clinical relationship faster than to ask permission and then to do what you want in spite of the clients response so we're constantly respecting their autonomy to make decisions about how they progress forward in their use disorder so the principle and overview the principles of these techniques are when we engage with the client that we're expressing empathy meaning we're listening to understand not to reply and the best I can tell you about that is to listen to understand we need to be silent you need to be able to kind of be still and just truly listen to what our patient is saying and I know that's very difficult to do within the context of health care it's very difficult to do in the context of behavioral health care as well but to engage and change behaviors that's what we need to do and so it's it's kind of like a state of mind that we need to get in here as we learn to listen and pull the narrative we can develop the discrepancies it kind of showcases the clients true ambivalence of wanting to and not wanting to do something and we can help them use their narrative to point out the inconsistencies in their thinking but it's not it's it's using their own narrative and then as a result of that we're constantly rolling with resistance it's like negotiating waves at the beach to avoid the really big ones you dive underneath and let it break over you so that's the idea here we're not we're not like pounding the way we're not like going into a full body we're going to duck under we're going to see it as the provider we're going to dunk under we're going to resurface and come in with a different approach right we're going to reframe it and then we're supporting self-efficacy whether you think you can do a thing or not it is your right and so we need to know if the client feels that they can do this so when we think about expressing empathy the key is to defining the principle this is like the basic principles of motivational interviewing work and the work of Carl Rogers the working definition of this is accepting and understanding another's perspective and I get it when working with patients with use disorder and high-risk use their perspective is sometimes very skewed towards what they think is right behavior working with patients and myself growing up in Appalachia you know there are patients that it has never occurred to them that they will live a life without substances that everyone in their immediate circle or family or friends uses something and that is a way of life and so you know having empathy for their context in their environment and how they see what recovery is can sometimes be very challenging to medical and behavioral health providers because it may be very skewed but we're going to listen without judgment or evaluation it's not about hitting the nail it's not about that at all so learning how to like hate the sin but love the sinner separate the addiction from the person and begin to understand who that person is sitting across from you acceptance and again just remember acceptance does not necessarily mean approval or agreement and in a lot of cases with addiction or high-risk youth use it doesn't mean that at all you can disagree and even gently confront something just to avoid conveying or passing judgment so we there's lots of ways to listen empathy we convey empathy by letting somebody know that we understand we accept what they're saying and that we empathize with where they're at so we use motivational enhancement techniques gives you lots of ways to reflect what the client is saying to you and take the story deeper and I think this is really some like integration of behavioral health that can be applied in health care like simple reflection skills just what the client says is you repeat it back and it says I hear what you're saying double-sided reflection where where you're feeling the discrepancies on one hand you want to get your children back but on the other hand you're not quite ready and you're not confident on how you're going to treat your opiate use disorder. Amplified reflections kind of amplifies or heightens the resistance that's heard so you're never and it's a tricky one so a client is maybe just adamant that they're not going to go on that medication for opiate use disorder I'm never going to do that I've heard about that medication and that's harder to come off than the heroin themselves and so an amplified reflection is just giving back the amplification of their statement to them is you're never going to take that medication it is not valuable to you never in a million years and when you meet their amplification with another amplification they hear it from a behavioral health standpoint it helps them hear it and maybe take another approach they might say well you know I had a friend that was taking this suboxone off the street and it was this back this constant back and forth if it's not going to help them what's the point so if we use amplified reflection it can pull some more of the narrative instead of the saying I don't know if that's the right approach right it's almost like you pull up a chair next to it self-motivational statements where you point out any change you've observed and ask the client how this was accomplished and then using summaries to pull together reframe or transition to a next topic. Developing discrepancies this is the direct part of MI this is kind of when we think about directing guiding and then facilitating in the middle developing discrepancies is kind of one more more on the continuum towards directing and it differs this approach differs from traditional person-centered counseling it's this discrepancy between the way things are and the way the person would like them to be and this is thick with people with addiction substance use disorder or high risk behavior it's the wanting to and the not wanting to it and but what's most important is we can't get to that unless we pull up a chair next to them and hear their narrative so it creates this gap between where the person has been or currently is and where they want to be the goal essentially to developing the discrepancies is to resolve the discrepancy by changing behavior. So there's some strategies that we do. We might ask questions like, tell me some of the good things or the less good things about your use, right? So we might pull up a chair like, if someone is in a love affair with opioids, they are doing something for the individual. Tell me about the good things about your opiate use disorder. What does heroin do for you on a daily basis, right? So, and then what are the less good things about that? So we hear both sides of the narrative. And in the skill set that this is a four quadrant box, the good things and the not so good things about change, and the good things and the not so good things about maintaining the status quo around their use disorder. What would your life be like five years from now if you don't make any changes and you continue to use, right? So these are all questions we can ask to kind of pull on their ambivalence and hear their narrative. I think developing discrepancies in a way enables the person to see how important change can be. It may be sufficient to facilitate change. It's this rift between the present behavior and the stated values and goals. And it's the best kind of setup for the client to initiate their change talk. It's when we get to this, when we're able to navigate these waters successfully, we can get to making decisions about change. They're verbalizing of ambivalence in what ways has your behavior been a problem? What have other people said about it? If it's not a problem now, let's say they're engaging in high risk use, how might your use eventually become a problem? Now, what are your thoughts on that? So you see, it's like we're asking them instead of telling them. In what ways has it been an inconvenience for you? Just a couple more slides here. Rolling with resistance. This is where we're gonna avoid arguing with our clients. Arguing with clients to change will necessarily force the client to argue against it. So this is traditionally reviewed. We talk about this as the patient and the client being resistant or in denial. So when that language is coming to your head, reframe that as I'm not pulling up a chair next to them. I haven't pulled up a chair next to them. In some ways, they feel like I'm battling them. So resistance in a way is this like clinical barometer of how well we're doing hearing where the client is, meeting them where they're at in their stage of change, and then engaging from that place. We often expect the patient to be in preparation or action stage when in reality, they're in pre-contemplation and contemplation. So rolling with resistance essentially means getting out of its way, ducking through the way that's coming in and not engaging with it. It's just like psychological judo. It's not met with direct opposition. We're essentially trying to use their momentum to their own advantage. It's like, come at me. Okay, now we're gonna use that story to plummet you into your recovery efforts. So we might see a resistant as the client arguing with us, interrupting us, denying us, denying everything we're saying or ignoring us. You know, we've all had patients or clients like this. So the arguing, the client contests, the accuracy or the expertise or the integrity of the clinician. When they interrupt us, the client breaks in and interrupts in a defensive manner. Denying the client expresses this like unwillingness to recognize the problems, cooperate, accept responsibility or take advice, or they just plain out ignore us. So use that as your barometer that you have it joined with the patient to truly engage around their use disorder in an unconditional empathic way. They haven't felt heard yet or that it's safe to be heard. And then, you know, when we start to engage and to pull out these discrepancies, ultimately we wanna support their self-efficacy. This is self-explanatory, but this is critical to our movement forward because change essentially means action. So similar to confidence, but it's more specific. Self-confidence is a belief in me. Self-efficacy is a belief in my ability to do so. We need to believe that our patients with use disorders or high risk use can change and get well. And often, all too often, providers see someone so sick with addiction. They have endocarditis, they have fluid everywhere. They're putting heroin in their port, in the hospital. They need heart surgery, but they're not willing because they don't think it's possible for them to get well. I mean, this scenario plays out all too often with providers that they think people, because of stigma with use disorders, are a lost cause. But so you really need to ask yourself like what you believe about someone's self-efficacy to get well and to recover from their use disorder, no matter how far, no matter what their bottom looks like, that do you believe in their ability to get well and their self-efficacy and can you support that? If change is viewed as necessary, but the client lacks the belief in their ability to make that change, it's not gonna happen. But when the providers believe in clients and they convey this, the client is likely to reflect this confidence. It kind of works as this like self-fulfilling prophecy. And we can do this very subtly and with grace, but essentially it's not abandoning them on their efforts or passing them off to somebody else. We can't make change for our clients and so therefore the client has to believe in their ability to make that change, to show up for that intake appointment at the outpatient doctor's office once they leave the ER or to continue on with their methadone treatment program and show up every day for their dosing and believe that if they do that, that the medication will help them return to a life of health, wellness and purpose. And we have to nurture that and set the stage for self-efficacy. And so to do that, we explore past successes and we help them build skills so they can walk before they run. But all of this being said about motivational enhancement techniques, I don't do this kind of in a vacuum as a behavioral health provider that works often with healthcare professional nurses and medical doctors and physician's assistants. I often think about your job duties and like kind of what benefits you in incorporating motivational enhancement techniques into primary care and what are your beliefs about your ability to be able to do this? I looked at a recent synthesis of implementation frameworks that suggested that understanding the characteristics of individuals working within healthcare settings is critical to thinking about how you go about organizational change. This particular study by Midbow and colleagues in 2011 looked at prescribers, nurses and mental health providers. And they looked at what their beliefs and attitudes were regarding counseling patients with health behavior change and how confident they felt in their ability to do that. What do they believe about it and what are their attitudes about doing it? What their self-efficacy was to support patients to make changes in health behavior, the extent to which they experienced job-related burnout prior to learning these motivational interviewing skills and what their time commitments look like. And this often, what these stories is often what they believed about it, what their attitudes were, how supported they felt in like being able to do it and how much they knew about motivational interviewing often equaled whether they did it or not. And so what the study showed is that nurses and mental health providers for the most part felt that if they had training about motivational interviewing or motivational enhancement, that they felt that their self-efficacy to support the patients in their change behavior was there, that they had the skills to do that. And of course, most mental health or behavioral health providers felt that they could do that. But often nurses and medical prescribing, prescribers felt that they were struggling with the time commitment. But I also wanna hear about you all. When you think about the integration of these skills into your role, what do you think your strengths and challenges are with doing more integration of behavioral health care? And that is all for me. Okay, thank you very, very much. That was excellent. And before we go on to some questions, I just wanna say this session has been recorded. It will be available in the near future, both at the International Nurses Society on Addictions website, as well as the American Academy of Addiction Psychiatry website. So anyone can review this as well. For today, there are nursing contact hours for one credit of contact hour that will be provided. There will be an evaluation sent out this week online that you will complete. And then we send out another evaluation 30 days from now as well that hopefully everyone would complete. So with that, I'll open it to some questions. I've been able to open this panel up. Many people did respond to the questions with the cases and they were right on target. Let me see what questions I can find. There were some questions about the slides being available. And again, like I said, this was recorded and they will be able to watch it and listen to it again at those websites. Let me just scroll down here. One was, give the client what they want to get the chance to provide what is needed. Can you give examples of what you can give the patient? Yeah, I think a classic example of this with patients with addiction and substance use disorder is pulling up a chair next to what they love about their drug use. So instead of dismissing this idea of not wanting to let go of the drug, but instead pulling up a chair next to that and saying, okay, let's talk about that. Let's talk about what you get from the methamphetamine or what it does for you or the opiates. It's helping you, I mean, and accepting what they're saying to you. Like, it's giving me energy to be the mother that I need to be to my kids. Even though it doesn't make any sense, right? It will ultimately lead to their kids being taken away from them. But for a second, pulling up a chair next to that, because it might be the narrative you need to help them with the solution. So what is that? Why do they need a drug to feel less fatigued? Oftentimes, we might find in somebody's narrative that maybe they've had untreated ADD or depression or chronic fatigue, and that they've been using drugs to treat these untreated things, but we don't hear that unless we engage in that conversation with them and accept it. Instead of judge it or dismiss it, like, you know, that doesn't make any sense, but like hearing it for the truth it is, that it gives you energy to take care of your kids. You're able to be the mother that you need to be. You're able to focus. And yeah, pulling up a chair next to it. I think that's a classic example of starting where they're at. So you don't want to go on medication. You don't want to go on medication for your opiate use disorder, but you found out you had hepatitis today. So instead of pushing medicated-assisted treatment today, one of my ways of giving them another, is there anything we can do today or talk about today to keep you and others safe from continuation of passing clinical diseases, right? So it's like, the idea is meeting the patient where they're at and their continuum of change with their use disorder. Okay. Here's another question. Says, sometimes personality factors interact a lot with clients' addictions. How do we cater to those? Like, some clients with cluster B personality traits may exaggerate their symptoms and share, and sometimes the clients may have an ongoing stressor in their environment, like maybe a dysfunctional family. If not catered to, they may continue to resorting to the substances. Yeah, definitely. I think that's a really important question, because we can't control the environments that we send our patients back into, right? You know, the reality is that our patient may be going back into an environment where everyone is still actively using, and that's the environment that they wanna go back to because they love their family unit, right? Or, as you mentioned, I like to think about my patients having withdrawal trauma. It's like trauma from experience, and so they exaggerate everything. To get access to whatever it is, the medication or someone believing them. My tendency as a behavioral health provider in these spaces is a similar technique as before is pulling up a chair next to that, is holding up a mirror to that. I'm noticing X, Y, and Z, and I wanna make sure that I'm able to help you and also keep whatever you say, if you're still engaging in high-risk use, or keep your recovery on track if you're on medication and you're in recovery from not relapsing. And so hearing those things out reflecting it back empathetically until they can get calm. But as a behavioral health provider, I'm not sure where nursing crosses into this. Sometimes with those cluster B patients, those personality that are kind of triggered very easily, maybe they're carrying trauma around that hasn't been treated, so they're getting a recovery, but they're walking around very reactive to things. So maybe it's just getting them treatment for the things that have been left untreated. And I think we're seeing a lot of that with untreated trauma and people being in spaces or in cultures that are triggering them. And so as behavioral health providers, we provide a lot of integration of mindfulness-based work that kind of overlays with cognitive behavioral therapy to help patients become aware of their reactive states. Yeah, I think that question is very important question to think about. And I guess it almost leads me to another question is like, how does that translate with nurses? Like, do you refer behavioral health in? Do you have the time to, do you have access to trauma treatment? What are the cultures or the systems in place to support those other needs as they surface? And therefore the symptoms of those things may be like a person, we might call that a personality or cluster problem, or how do you deal with the family that is still actively engaged, right? Yeah. Okay, and then there's another question. How might you respond to a client who appears to be trying to shock you and possibly test your power? For example, if you don't get me into rehab, I'm going to dig my heels in and make a stink. Or another example, if you discharge me, I'm going to use and it'll be your fault. Yeah, that's a good question. I, clients, I feel like test us a lot. So even in my world too, in behavioral health, you know, clients are coerced to be into treatment and therapy and they dig their heels in. And so it's a similar approach, you know, it's pulling up a chair next to that and not being reactive to it. And I know, and also wonder, I also remind myself that it's almost like a testing zone. Like patients sometimes test the provider before they share what they really need to share. And I also believe it's a fear response. So maybe at some point I need to, we need to get to a space where we can talk about what's available to them and I can help you make the best decisions for your life. And maybe those decisions haven't been explained clearly to the client or their autonomy hasn't been respected. I think patients and families were kind of up against an epidemic where people feel like they don't have a lot of information about what the best course of action is. And families are feeling that way and first responders are feeling that way. And patients are that addiction is a very dismissive healthcare concern that is often, I'm not saying, it's often pushed off as somebody else's problem. Let's get you out the door. And so if we can have empathy for this fight that they have to get themselves access to care and use this as a side to say, you know what? Yeah, let's see what is available. Let's bring the social worker in and talk to you a little bit more. And in some ways, maybe your hands are tied, but I can still give you resources and education today so you can still make healthy decisions for your recovery moving forward. Okay, now can you advance the slide forward? I think there's just a couple more I need to cover. So we do have a PCSS mentoring program that's designed to offer general information to clinicians about evidence-based clinical practices in prescribing medications for opioid addiction. The mentors are a national network of providers with expertise in addictions, pain, evidence-based treatment, including medication-assisted treatment. We utilize a three-tiered approach, allowing every mentor and mentee relationship to be unique and catered to for specific needs of the mentee. And again, for more information, visit the website that's listed on the slide. We can go to the next slide. Can you move the slide one more forward? Sorry. And we did answer the questions. So again, we thank you for being here. Dr. Callistra, thank you very much. It was a superb presentation. I'm sure everyone benefited greatly from it. Don't forget, these have been recorded. They will be on the American Academy of Addiction Psychiatry website and the International Nurses Society on Addictions website. Don't forget to complete your evaluations. And again, you will be awarded your CE certificate. Thank you so much for attending. Thank you for being here. And we will now end the webinar. Thank you. Thank you for having me.

Dr. Al Rundio

Dr. Angela Calistra

motivational enhancement techniques

engaging with patients

substance use disorders

high-risk behavior

expressing empathy

developing discrepancies

rolling with resistance

supporting self-efficacy