I don't know if I should start over, but hi, I'm Stephanie. The recording just started. So we'll just keep doing that and I'll just go on a loop and we'll introduce, I'm kidding. So some of the research, have you all done the wound care already? Is that a, can I have like a hand raise if you've done the wound care training and you've any, anybody do the xylosine training? So this is part of that curriculum and essentially just to give you a little bit of context of where it lives inside of that curriculum is the xylosine training talks a lot of, you know, it gives a little bit of history in such a fascinating way. Every time I hear it, I learn something new of the impact of the history and the impact of xylosine as a newer adulterant in the opioid supply. Also then, and also the impact that it has had in terms of skin, skin wounds for our community of folks who use drugs. So that then leads into how do we, what can we do, what can we offer? And this whole curriculum was designed in the, with outreach folks in mind, right? Our intended audience when we built this out was individuals who work directly with people who use drugs in either outreach street settings or in quick interaction clinics, whatever those may be. So maybe they're drop-in centers, maybe they are places where folks are getting other kinds of services and when we see, you know, an addition of wound care asked for by the community and then folks going like, we don't have the staff or the training to provide the kind of services that our individuals are asking for. And we saw that over and over and over in agencies in New York City, which is how we landed into this space. It was really a needs-based response that our team had as a team of medical professionals in a health sciences campus in partnership with the Department of Health in New York City. And so that's what built it. And then we've been so fortunate to be able to share it more broadly. And I'm really excited to bring it to you all today. I'm sure it's a beautiful evening in Vermont. So I'm grateful that you would share some of that time with us and to brush up on these skills. So the wound care part was really the nuts and bolts of like, how do we actually provide a service? And it's it's a service that can be provided and impact that's tremendous. For laymen, you don't have to have a health care background. In fact, we found that our health care providers were also a little gun-shy about providing outreach wound care. And so we've designed it in a first aid format so that we can really offer something that is valuable as part of the laundry list or menu items of services that we're already offering. And then we would be remiss if we didn't include this section on a little bit about MI-guided renegotiated interviewing, because you might have noticed if Vermont, if people who use drugs in Vermont or anything like people who use drugs in New York, that sometimes they don't they're not excited to receive our services right away. And so the having some of those nuanced conversations that explore what are the barriers to receiving the care that we might be able to see as as providers are so crucial and they might feel a little bit more ambivalence about. So I'm a licensed clinical social worker. I have a KSAC. I'm not sure what they call that. Every state has the same international certification, but each state calls it something a little different. When I was in Pennsylvania, it was a CAC. In New York, it's a KSAC. And I've been working with people who use drugs since I was 18 years old. And prior to that, I was a person who used drugs. And prior to that, I was raised by people who use drugs. So my whole life has been really just the community of people who use drugs, particularly opioid dependent folks. And so this moment in this opioid epidemic, this moment in history, which has unfortunately moved into an era, has been really something that's been feels like a call to action for me. Right. So the Opioid Response Network is a SAMHSA funded program that has that assists states, organizations and individuals providing resources and technical assistance that they need locally to address the opioid crisis and stimulant use. So that is this is an example of that. There is a whole repository of incredible trainings and a whole roster of incredible trainers that can be accessed through this network. And it is of no cost to the agency. And so if there's any other trainings, workshops that you feel like your organizations could use, but you think, oh, my God, we just were already under resource and we don't have the time to build that wheel. You can reach out to our to our team and connect in the way that you did to build out this training. And the support is really there. The technical assistance is available through evidence based prevention, harm reduction, treatment and recovery of opioid use disorders and stimulant use disorders. And the idea here was to not to try to reduce some of that duplicative services. I'm sure you've seen this in Vermont as well. Right. We are like if we just were talking to the other agencies, maybe we would we would be a little bit more effective and efficient in our service to our community. And so they receive requests and then each state and territory has a designated team. If you have any questions or you want to submit a request, here's the here's the. Places to do it, different different means to do so, and I think what he said, we'll be sending out these slides, right, so you'll have this. I don't feel like you have to take a photo at the moment if you don't have the time to. All right. So let's get into it. The first challenge is going to be that we are I'm going to ask that you identify a change in your life that you have been considering making. So something that you maybe have toyed with the idea, maybe you've tried a couple of times and had limited kinds levels of success. And. You maybe feel two ways about it, that on one hand, you'd really like to see this change happen, and on the other hand, you're kind of you're putting it off or have some resistance. The I encourage you to take a risk and whatever that whatever that challenges that you that that you think about and you are going to share with another person. Heads up, the only the only request that I have is that it be sincere, right? So take as much of a risk as you're willing to take. But the sort of the only requirement is that it be an authentic thing, like a real thing that you that you have considered and sort of had some struggle with. So examples of some benign things that people talk about are often like their relationship with exercise or or particular food or or the sort of well-being habits through some, you know, are in our individual's own relationship with substances and so on. All right, so here's what we're going to get through today, and I promise I know it seems crazy, but we're going to do this in the time that we have and I promise to get you out on time. So we are going to develop an understanding of motivational interviewing spirit and principles. We are going to come we are going to come up with the we're going to be able to define identity and identify change talks, sustain talk in the writing reflex. We're going to practice some concrete and my strategies using something called ORS, which you'll learn about later. We're going to define and learn the steps of a brief negotiated interview, and we're going to practice a brief negotiated interview as well. Can I just stop and ask quickly, where where are you all like? What kind of agencies do you work in? I want to, you know, make sure that this is as relevant as possible as someone who want to get. Are you all in the same organization together? Are you in various organizations throughout the region? You want to give me just sort of a sense of who's in the space with us? This is Steph. I'll just say one of the people that worked to organize this. So this was put out predominantly to EMS agencies. So I know that there's a ton of them and then also recovery centers, which I see people are putting on right now. So it's EMS folks, recovery centers, SSPs, and then other organizations that are working within SUD. What an awesome mix. Thank you. I'm looking through that. So we got some harm reduction folks. We have, I see a turning point. Awesome. Welcome to everyone. Thank you so much for being here. My name is Brandon. I'm Brandon. I'm a new member to the Medical Reserve Corps in Bennington County, Southern Vermont. Welcome. Thank you so much for being here. I see we also have a school nurse. I'm sorry. Go ahead, Brandon. Yeah, no, I just just a real quick background. I'm a retired army medic and a firefighter, cop, EMS, kind of a trauma guy. So this, this makes sense to me. Thank you. Yep. If you're a trauma guy, you'll, you'll, you'll feel right at home here in this space. Thank you, Brandon. Thank you. Okay. So that gives me a nice, and I love, I love when there's a nice mixture in the room. Please feel free to speak up. I know that it's I don't know about everybody else, but I, I zoomed for like 17 hours a day during like quarantine level pandemic. And when it was, when I was able to go out again, like I never wanted to open the zoom again. So I know that I understand that it has value. I still see some, some of my own clients this way. I still do lots of meetings this way, but I know that sometimes, especially when you're doing like an evening training, I just want to like recognize that this can be tough. So in terms of just like feeling like you can stay engaged and feel like you're in, in the space. So please feel free to jump in, share, bring your experiences. It's, it only makes it more enriching. So I just want to formally welcome all of that. Okay. So show a hand so you can do the little raise hand, or you could actually raise your own hand. How many people have done MI training in your work? Motivational interviewing. Is this new for some folks? Sam, Eva, awesome. Okay. So for some of you, it's new for some of you, this will be a refresher. I'm going to do what we're going to do is motivational interviewing lightning style. And I will say that MI is something that takes a lot of practice. You know, those of you who are trained in it, I think certainly could attest to that. You know, some people practice it for years and years and years and years. I'm one of them. I'm always, I'm always refining that skill. The, but there, there are some pieces that even if this is brand new for someone, I think we can garner some of the, the more integral pieces that we need to do this brief negotiated interview and apply some very specific applicable skills, right? But the MI as a counseling technique was developed in 1983. I am older than this, right? So this is a fairly new, as far as my counseling styles go, a fairly new technique. Marjorie, I just want to make sure, were you just raising your hand for MI or did you want to pop that in? I saw your hand up. Okay. I think she was just raising it for MI. Okay. So it was later refined by Stephen Rolnick as well. And Miller stayed involved. And they, they were both individuals who worked with folks who had, who specifically wanted to shift their relationship with substances. Right. And I think if we look at the definition, it's defined as a directive client-centered counseling style for eliciting behavior change by helping clients explore and resolve ambivalence. And that main, I think the most important word there is ambivalence, right? And ambivalence is this uncertainty. It's like on one side, this on the other side that I feel this way, but I also feel that way I'm kind of on the fence. Right. And, and if we can just really think about this metaphor of being on the fence, I'm feeling two ways about something, it's really going to help us break down the foundation of what motivational interviewing is, which is really the, the journey of as a, as a provider or as a support person in whatever ways we are interacting with folks that need support and help. We are hopping on motivational interviewing says, okay, like I see somebody struggling to make a decision. I see that there, there, there might be something that I think is really important that I can identify as like maybe even like crucial, right. And they might be resistant and, but I can see that they're feeling, they're not just completely resistant. They're like, part of them feels like they might want to, they might see the need to make this change. And the other part of them is like, I don't know. I don't think so. It's the, the idea of the provider hopping on that fence and sort of sorting it out with them and hopping on that fence. I want to forewarn you is uncomfortable, right? So it is, it's a decision as a provider to sort of welcome that discomfort for yourself as well, which I know is tough. And I know the work is hard and I encourage you all to take care of each other in response to how difficult this work can be. But that really, if you really think about ambivalence, it makes sense that folks who were working with people who use drugs were the first people to identify and develop this, this model, because I would dare you to find a population with more ambivalence than people who use drugs, right? We just, we, it's a, it's a, it's a community of folks that has a disproportionate amount of ambivalence, right? To the rest of the population. So what's the spirit? The spirit is partnership, compassion, acceptance and evocation. That evocation part is important because it's not, it's not stagnant. We're not just like, it's not this, like this idea that like, if I, if I, you know, do the self-efficacy social work, meet you where you're at, right? That, that means that we're not going anywhere. I just meet you there and park, you know, and, and park a spot right there with you. No, we, we are, we are intending to get somewhere, but how we get there is a little bit different. I told you I've been doing this since I was 18. And I know that you thought that that was five years ago, but that was actually a really, really long time ago. And when I started in this work, I want to tell you that there, we, we didn't, where I was, I was in, I was in Pennsylvania. There was like, not, I, harm reduction was a bad word. It was a bad term, right? It meant like, you know, we were told like harm reduction meant that our abstinence-based treatment centers were going to be handing out methadone in our, in our treatment centers. And we weren't going to ever have like true abstinence anymore. And there was all of this discord and tension between like newly rising harm reduction conversations and communities and this like very longstanding, more sort of 12-step abstinence-based community. And what I was taught was that the folks that I worked with had a disease and that disease sort of hijacked their body, right? And that, that my job was to, was to, was to get them back. And if I met that resistance, that resistance was not them. That resistance was the disease and that my job was to fight it. Anybody familiar with this kind of worked in facilities that had this kind of model? It was the, it was the best we knew at the time. It was still, it was still a step forward from therapeutic communities that did things like have our, have our communities of people who use drugs do things like wear signs that say, I am a junkie and walk through the park. And, you know, it was the tear people down to build them back up model, which we knew, we now know shame is not motivate, a long-term motivator, right? So this was a step better. It was a step in the right direction, this disease model, where it was less blaming the individual and more blaming this individual's sickness, right? But it did require this toe-to-toe, head-to-head combat. And that is antithetical to motivational interviewing, right? So once you are in, if what we are intending to do, and I'm gonna talk about it this way, if you're intending to have a motivational interviewing congruent engagement, right? It would not include arguing or like a battle or combativeness, right? It would, it sort of, it develops, it rolls with that resistance, right? So like that, we anticipate that that resistance is coming and it's, you know, and it's, that's part of the journey. It supports self-efficacy, develops discrepancy, which again, we're gonna, I'm gonna go back to the fence. You're gonna be like, I'm so sick of this lady talking about the fence, but it is, it's the developing the discrepancy is just sort of pointing out what's on both sides of the fence. Can be incredibly powerful, particularly when somebody's sitting there with you and you know that they're in the dirty bathwater, right? You know that they're on the fence with you. Expressing empathy. So here's an excellent bit of news that is just a, I think an unintended benefit of motivational interviewing in practice. Those agencies that I told you that I worked at early on in my career, we did that disease model. Like I would, they told me, they were like, Stephanie, we got to get our people back. We love them. We know that they're in there. The real person's in there. We got to find them, get in the boxing ring and fight that person's disease, right? So the difference of that is sort of like, the way I think about motivational interviewing, it's like, nobody's in the boxing ring. We're, I'm shoulder to shoulder with my client and we're looking at the boxing ring together and we're curious and we're like, what's going on in there? How do we solve this, right? I'm on the same side as you. We are partners, you know? And the nice thing about that is, it's such an easier job. Like the, those agencies that I worked in, the like average turnover rate was like six to 18 months, right? People didn't last very long. I've been in my current harm reduction role for 12 years, right? And that is because I'm part, I'm not fighting with my clients, I'm partnering with them, you know? And it really does reduce that burnout. It's a much, it is a much more, a much less strenuous workflow, right? When you're not fighting people all day. Okay, so role play exercise. We can do this. How many people do we have on, Courtney? 18. 18, okay, perfect. So what we're gonna do is we're gonna, we're gonna go into breakout groups and I'm gonna have you do something very specific. And I know it's gonna sound a little bit odd, but trust me and let's try it, okay? What I'm gonna have you do is go into your, you're gonna go into breakout rooms, you're gonna be with one other person. One of you is gonna decide, I'm the person that's gonna share the thing that I'm trying to change. And the other person's going to be the person that helps them. The person who shares the thing that they're trying to change, all you're gonna say is, here's something that I've been struggling with. How can you help me? And then you are going, then the helper is gonna tell them all the things that they can do, that they can think of as a one-way conversation. Just put, we don't have a lot of time, so pile it on. Give them all the ideas and advice that you can of ways that they can improve this thing that they're struggling with, okay? And the person who's, the person that is shared, that don't say anything, just receive it, okay? So resist the urge to ask questions when you're the helper, just tell them things that they can do, okay? Because we don't have a lot of time. So, Courtney's gonna get you breakout rooms. Yes, I think I did this correctly. Everybody, okay, so, would somebody who was seeking support be brave enough to share a little bit about what that experience was like with the group? I wonder if I can. There's some folks still chatting in their rooms, FYI. Okay. I know my group, we couldn't, I couldn't hear the other person. I had two other people. One I couldn't hear and the other one was muted and I tried to get either one of them, I couldn't hear. So. I'm sorry that that didn't work out so well. That's okay. Did anybody have a fruitful conversation? Yeah. Yes. It was really hard not to ask questions, not gonna lie. Yes. So you were the helper, Kimberly? Yes. Who was your? Stan. Stan? Yes. Stan, would you mind sharing a little bit about what it was like to hear some of that feedback? I think it was fairly fruitful, actually. She came up with some very good ideas about a somewhat complex issue that regards withdrawals from alcohol. I thought that she had very good advice on changing my diet. Okay. In order to reduce those. Stan, was that new information for you? No, not new information, but I wouldn't have been able to have call it up that fast and in that much detail as she was, so. So you ended up with someone who was like an expert in exactly what you needed and was able to give you some really good advice. Yeah. Wonderful. Do you think that that is going to have a market shift? And we don't say this. I wanna preface everything that we say in this debrief by saying that this whole thing was a setup, okay? It was not intended to go well and I'll explain why in a moment. But do you think, Sam, that you will have a market shift in your behavior that you were concerned about as a result of that interaction? Possibly. That's incredible. That's wonderful. I applaud that. That would be a really excellent unintended consequence of this exercise. So that's wonderful, Sam. With Kimberly? Yes. Kimberly, tell me what it felt like to just give that information. It felt like super bossy. I felt like I was just, like I wanted to be super helpful, like I can fix this. And so my practice in general is like, I can't fix this, but what can we do? So it was really hard for me to step away from that place of not including that person in the conversation and just be whipping off ideas. And it was really hard to keep coming up with them. Yeah, it's a lot of pressure on the person to have the information, right? It's like- It was really hard, yeah. Yeah, and it sounds like you already have a lot of this training and this background, so it didn't feel natural to you, right? No, it felt very uncomfortable. I felt like, oh my God, he's gonna tell me any minute, like, okay, lady, I already know that. Yeah, yeah. Like, you're not telling me anything new. But he was wonderful, so. Turned out to be great, but it often does not, right? When there's a one-sided conversation. And it's so hard to also resist the urge when you don't have this training to do this thing called the writing reflex, right? Correct, yeah. Which is this idea that, I know the answer, and I told you I'm a social worker, we're the worst at this. Like, we are like the worst offenders. We so badly want everybody to get better, and we just wanna give everybody a hug, right? Right. Because we can see the past so clearly, and we can lay it out for you. And we're like, okay, you just gotta do da-da-da-da-da. Da-da-da-da-da. Okay, I said, you know, my friend and I used to have, like, we had this t-shirt that we used to get a picture of, that we hung up on our wall. You should've just done what your case manager said to begin with. And because, you know, it's like, because you can see it, but unless the person buys into that or has some ownership in it, just telling them, which Sam was wonderful, but just telling somebody just feels like it's just gonna go, they're gonna take it, and then you don't know what's gonna happen. Right, right. The evidence doesn't show that that's the most beneficial way or the most likely way to have a sustainable change. Right? Right, yes. So when we have, when somebody has that buy-in. Sorry. Oh, that was, I think that was background. So anyway, yeah, this is the, this exercise was intended to intentionally experience that writing reflex, right? And someone who was receiving the information, did anybody feel like, this is stuff I already kinda know, and certainly I've tried it already, and this isn't really the issue. Like, it's not a lack of knowledge that's causing me to not be able to make the change that I'd like to make. Ava, you wanna talk a little bit about that? Oh, sure. I brought up, I have a young dog, and he's got a few issues still, because he's a young dog, and I brought up mixed feelings about shock collars, because they've been suggested to me. And I was partnered with Rebecca, who did a great job of looking at the issue, but it was like, yeah, exactly. Like, yes, it was kind of affirming, but it wasn't helpful at all. It was just like, thanks, yeah, you saw my situation. And like Rebecca said, Rebecca's not a dog trainer, so if I had brought up something about substance use, or anything in her field, maybe it would've actually been more affirming, but like you're saying, it was just like, why are you, like, this is not getting us anywhere. Right, right. And so if somebody walks up to me, and I'm outside smoking a cigarette, and they walk up to me, and they're like, hey, do you know that that causes cancer? I'm like, oh my God, no, I didn't. Let me put this out, I'll never smoke again, right? And so oftentimes, it's, you know, and as ridiculous as we all know that that sounds, we do have folks, particularly often in the medical field, that are like, I'm gonna tell you that this is bad for your health, and I'm gonna recommend that you either do more of this, or less of that, and I anticipate that you're gonna take that information because you did come see me as the expert, and you're gonna go do it, right? And we just know that that's not how change happens. So when we start to, you know, when we see ourselves moving into that space, we know, okay, I'm no longer in an am I congruent interaction, right? I'm trying to be persuasive, I'm trying to push an agenda, I'm trying to, I'm getting, I'm sort of on the edge of becoming argumentative. That's the other time when you're like, when I'm like, I need this person to do this, and they're not doing it, it can be agitating to the provider, right? It's like, why aren't you listening to me? And it's like, actually, we're supposed to be listening to them, right? So that is sort of one of those places where it's like, oop, okay, let me get back into my am I. So here's, in motivational interviewing, some of the things that we listen for are these things called sustained talk and change talk. Sustained talk is the term for, again, we're gonna go back to the fence, right? On the fence, on two sides of the thing, we got like, on this side, the shock collar could help with these things, on the other side, I'm really conflicted, I don't know that I wanna use this thing, right? There's the two sides of our shock collar. It's sustained talk would be the side that is, the reasons to continue what you've been doing. And the change talk is the side of the fence that is, here's some reasons that I might wanna shift my behavior. Very simple. Motivational interviewing really encourages us as practitioners to help craft conversation and questions and dialogue in ways that elicit as much change talk as possible. And there's good reason for that. I mean, it makes perfect sense. What it does is it then has people articulate their own reasons for why they are invested in making those changes, which I think Kimberly spoke to so beautifully, right? About like, I didn't want to, I didn't wanna like lay out all this advice on them. Like I wanted to hear them, I wanted to hear their buy-in, right? That's the change talk. That said, I wouldn't throw sustained talk out of bed. I think I utilize sustained talk as part of my MI, part of my MI interactions, maybe more than a lot of my peers do, and I'll tell you why. So the sustained talk is all the reasons that I don't wanna change, right? It's all the reasons that I'd like to continue with the behavior. And that might mean continue with my substance use. That might mean continue not getting my wound treated in this particular setting that we're talking, in this very niche space that we're talking about today. That resistance, and I don't even like that word because that word really does, it does have a lot of, it puts a lot of blame and onus on the individual, like they're resisting, right? Like, and resistance is a word that we use. We talk like, it's field for law enforcement, resisting arrest, resisting authority. It's just like, it has a lot of negative connotations, but it is that pushback, right? That is an expected part of the change process. That said, the more I understand why somebody wants to maintain something that's causing them harm, the better my likelihood, the better I feel equipped to help in the problem solving process together to really understand what's going on, right? For example, when I meet someone for the first time that has an opioid use disorder, and we have a chance to have a little bit more in depth of a conversation, one of the questions that I'll often ask in like an early assessment is tell me your love story with heroin, right? And oftentimes that catches people off guard, but what it does is it, one, it says that I understand that it's serving a function and it probably showed up and it serves such an incredibly important role when it was first introduced that it felt like a love story, right? And I have never had a single person tell me that they didn't have one. What they were solving for, right? Oftentimes it's a failing in our larger healthcare system, particularly often our mental healthcare system, right? How many of us have seen that? I mean, not a single person who's worked in this field a day hasn't witnessed a person who didn't get the kind of care that they needed and then went in seeking to navigate their own mental healthcare on their own, right? And then as a society, we blame them for that and call self-medicating like a negative term. It's actually kind of on us as a healthcare system to have not provided them with the kind of support that they needed and left them to their own devices to figure it out, right? And oftentimes people discover these things with what I call human trials, human self-experimentation and discover things that we then test later and find out they were right. A great example is people who experienced paranoid delusions using alcohol and cocaine as a combination to reduce those delusions. It's a terrifying experience when you realize that the things that you are experiencing are a solo experience. They're not being shared with other people. Folks are, it's incredibly scary. Those kinds of delusions are, you know, we might as a society be taught to sort of back away from folks that are, or feel fear when people are experiencing that kind of psychosis but I think no one's more afraid than the person who's experiencing it, right? So that's a great example of like, if I understand, oh, this person was experiencing incredible anxiety and depression, and then they found opioids and it solved for that, right? And then at some point it wasn't even about that anymore, but that that was the original solve. I know, okay, there's a really strong likelihood that if this person reduces their substance use or ceases their substance use, that stuff's gonna resurface and we need to make sure that we have a team in place, right? And that's just like one example, but understanding what a person is solving for, you know, I think that's a really important empathy piece of harm reduction generally, right? To not blame folks that use drugs, but to understand that drug use is a part of the human experience that has happened since the beginning of time and people have used it for all sorts of reasons, right? I'm sorry for the guests and all the thoughts. Oh, there we go. Okay, so what are some of the skills and core strategies that we can use? This is, I told you there was these ORs and, you know, we love our acronyms, but it stands for some of these core strategies that we can use when we're engaging with someone and we want to have a motivational, interviewing, congruent engagement. So it stands for open-ended questions, affirmations, reflections, and summaries. As just a quick context, like I said earlier on in the training, this training was developed with outreach peers in mind as the intended audience. We knew we would adapt it for various different folks that were interested, but the examples in this, that I'm going to use here are in that context, just to give you some background. Okay, so open-ended questions. So an example of a closed-ended question would be, have you considered going to the doctor? So that only has a couple of different possible answers. Yes, no, maybe, I don't know, whatever, right? But what does it do? Does it encourage conversation or close the conversation? Closes the conversation, right? So some other ways to engage would be to say something like, what are some of the treatment options you've considered? What are some concerns you have about this wound? What do you think are some possible outcomes if this goes untreated, right? So we're not just talking about a street outreach, but a street outreach engagement in which someone has a, is a person who has an active wound. So these options would engage further conversation, right? Affirmations are a way to really give credit or acknowledgement. They often start with the word you. Really good with rapport building. Unless you, unless it is perceived that the affirmation is in some way disingenuous, our folks are really, really excellent bullshit identifiers, right? They're like really good at knowing who's authentic and who is not. So excellent judges of character. So the only thing I would say is in terms of affirmations, I would say, just make sure it's sincere. That said, anyone who's having a conversation with me, I found I can almost always find a sincere affirmation in just the willingness to have the conversation, but it can acknowledge things like struggles and difficulties, successes, skills, and strengths. It can affirm someone's experience. Like, you know, it says in one of the examples here, it's just a very validating affirmation. Just you have been mistreated by healthcare professionals in the past, period, right? This isn't intended to have a further conversation. That's, or to engage in this particular, in this particular dialogue, we might continue the am I congruent conversation, but this is intended to be a statement of validation and affirmation, right? Your hesitation to seek care is understandable. Your willingness to have this conversation is courageous, right? Can also acknowledge goals and values. You know, so these types of things I think are really excellent in rapport building, which for, I think we have some folks here that may not see the same individuals as often, right? Some EMS folks that may see somebody once and never again. And you might think, can I really make a difference with some am I, like would an am I congruent conversation make a difference for a person that I see? And my answer is absolutely a thousand percent yes. And we're going to talk about that as we get to the brief negotiated interview. I will say that am I was built with the intention that Miller and Rolnick, they were like sort of old school, got to sit down with their patients on a weekly basis or biweekly sometimes and sort of chip away at this thing with the same practitioner, same patient chip away and see the impact of that am I over time. We may not be in circumstances like that. And quite honestly, the healthcare system, the way that it is, oftentimes our population doesn't get that level of access to care if we're being quite honest, right? So, but thankfully this has been measured in these brief interactions and it is incredibly valuable. Okay, so next the R stands for reflections. So reflections are mirroring content or emotion in a communication. Key strategy in developing discrepancy. So that again, just pointing out on this side of the fence, this on the other side of the fence, that usually ends with a period. In this strategy, in the use of reflections, I actually think a lot of the power and a lot of the work in the reflection happens in the silence that comes after it. And it is for the practitioner, this is a place where you will feel that discomfort of being on the fence or being in the dirty bath water with your client, right? And they'll feel it too. But I think that it's identified for the client as a shared experience in that moment, right? Because you are raising it and then you're sitting with it with them, right? So it's something like your past experiences have led you to not trust healthcare providers, but you're simultaneously concerned your wound may be infected, leaving you at risk for sepsis. And then we're just quiet for a little bit, right? You want the pain to stop. And we sit with that silence and it's uncomfortable for everybody, right? But that's like, know that if you've struck some of that, that's kind of the, it's like it's, that's where the work is happening, you know? And then, oh, yes, please. I'm sorry, I just had a little question, Stephanie. So, and you can tell me if I'm doing this wrong, but one of the ways that I've used like the summary or the reflecting, like on the discrepancy is when I reflect back to someone and I say something like, you know, I've heard you say that the reason that you've continued to use is because you've been suffering. You know, you're feeling like no one is listening to you. You're not, you've gone for help multiple times and felt unheard or unhelped. But then you also say that the next day you feel so guilty and you don't feel well. But then the first thing that you wanna do is go use again. So, and like, I say something like, I just want you to help me understand so that I get this right is, you know, what's the best way for me to help you? I'm like, do you want, how can I help you best? Can I help you reconnect with a provider? Can I, I wanna understand what you need the most help with. You need most help understanding the guilt and shame. Are you more worried about trying to work on getting sober? You know, because they're telling me two different things that they're feeling about the same action. So I try to, and maybe that's not the right place to do it, but I try to sometimes parse out what's the bigger issue in that moment. Is it, they feel so guilty that they just go use again and they don't care that they feel bad and they feel bad again. So like, and so sometimes I use it that way and maybe that's not the time to do that. Well, you know, a lot of the time piece really is often, often like environmentally and setting based, right? But that beginning piece where you said, so I hear, you know, this, and then I hear that, that is called a double-sided reflection. That is the developing of discrepancy. That's sort of putting it out there. These are the two things that you've told me. And then to follow that up with, so how can I help, right? Might help move them into that, into that space where they start to develop a plan, right? Which is where we ultimately want them to land. If you see someone pulling away when those things are, when the developing plan part is presented, I would just stick with the reflection and then you can go to a summary, right? Okay, so, you know, here we are. And you don't always, to be MI congruent doesn't mean that you always have to have or leave with a plan. You can just leave with, this is what you've told me, right? Okay, yep. And that doesn't mean that we haven't like completed our job necessarily, but what it does mean, and you really do gauge person to person, right? What kind of rapport you have. Are they asking for it to make a plan? Are they recoiling when you start talking about the plans? Does it look like they're feeling stressed, right? Because then we can just sit with, huh, let's be curious together. So these things are happening at the same time. How does that sit with you? How do you navigate that? Sounds like you're really like, and you could use the fence. Sounds like you're really on the fence about this. Like, what's it feel like to be there, you know? And sort of digging into that exploring part, even though we often want to jump to the plan part because we really want to see them get better. Sometimes that staying in that discomfort with them will actually sort of have them lead the plan conversation. Maybe not that interaction, maybe it'll be six months from now, right? But it's the seed is planting, right? Thank you, that is such a great question. So in summaries, it's awesome way to transition, especially when we've sort of moved into this brief negotiated interview setting where we're like, okay, I got five minutes, right? Which is why I intentionally put a time stressor on our conversation earlier that was intended to not be a mind congruent. It was intended to pull out the writing reflex, where I was like, we got to go fast. So, you know, tell them everything that they need to know because this is designed to be in settings where when we get to the brief negotiated interview, it's designed for very quick interactions. So again, our instinct might be like, we got to get it out really fast and get them to the help they need. But to stay in this am I congruent space would be to sort of get comfortable with the discomfort, right? That we may not be able to solve in this space, but we might be able to present a new way of looking at this dilemma that our folks are grappling with and really develop an allyship, a partnership with them that's going to put us and people like us, we are not just representing ourselves, we are representing all of the people that do our work, right? Many times the folks that we work with have not been the best, they have not been treated with, provided with stellar care. I say that with great sarcasm. Obviously, I mean, maybe Vermont's different. I have not worked in Vermont. So I want to leave space for things to be different there. But my guess is that your folks receive a lot of the mistreatment in healthcare settings and places that they go to and social services offices and various places through our criminal justice system and et cetera are treated disproportionately poorly, right? And- Stephanie, can I jump in on that real quick? Yes. Just, I wholeheartedly agree with you just coming from the trauma world. A lot of that I think can be attributed to just there not being enough providers and caregivers necessarily spend the amount of time that is truly needed to help these people. And as a result, for every person that we come in contact with, we have to navigate a mountain of paperwork afterward. So it just takes away from face-to-face time, which handcuffs us, that puts us in that head space of, I got to get this all out right now. A thousand percent, Brandon. Thank you for sharing that. Those systemic challenges and actually, Courtney, is this group doing the fourth part of this? Yeah, so they're getting all four modules as well as a compassion fatigue. If you're- A little compassion fatigue sprinkled on top. I love it. Brandon, please make sure you show up for the fourth module where my amazing colleague, Mike, is going to tell, is gonna talk a little bit about some of those organizational challenges, some of those, and how to navigate some of those hurdles in terms of funding and staffing and resources. And where do we get the kits? And what do we put in the kits? And where do we, you know, all of the kinds of things that are those more systemic challenges that our organizations and our caregivers across the globe face, but in particular, communities that are really rattled by the opioid epidemic. We're just, I mean, this is really hard work, folks. I wanna recognize and send a call out to every person that works in this field to please take care of each other. So, you know, those kinds of peer supports and sort of quality initiatives inside of organizations, looking at ways that we can streamline things, looking at ways that we can be more effective, looking at ways that we can close some of those gaps. It, ultimately, we are better. And when we are better, the services we provide are better. We can better treat our community when we are caring for ourselves as well. And certainly when our organizations have the support that they need. Stephanie, this is probably a stupid question, but I'm gonna ask it anyway. I doubt it. Just coming from the background that I have, when we encounter really stressful events or large quantities of challenging situations, one of the things that some of the agencies that I've worked with have done after is called critical incident stress debriefing, where everybody involved, it's basically like a, just, it's a big group therapy session, just to get it out and vent. I wonder if maybe there's a way for that to become a little bit more readily available or... Stephanie, did you wanna respond to that? Yeah, so, sorry, recovery centers, I can't offer you the same support. But in Vermont, first responders, and that can be either like EMS, law enforcement, fire, ski patrol, department of corrections, et cetera. There's six groups, I'm not remembering them all right now, are able to access both the emergency response are able to access both trained peer support, the secure, which is the pain, peer support, trained providers, and also like critical incident debriefing. So it's available to both like crews after like a critical call or whatnot, but also even individuals. I can definitely, if people wanna put their emails in the chat or can reach out to me, I can put my email in the chat to provide more information. But it's basically, so CISM is one of the components that is offered, but it's trained first responders who are working within the world in Vermont, also with like a trained counselor who is, many of them have some experience. We haven't quite gotten people of like, active experience, but they have really dedicated themselves to kind of getting to understand first responders and the world that we live in. So I can put my chat or I can put my email into the chat and definitely send more information, but it is available to all first responders in the state of Vermont through a grant that we have. That's awesome. Woo-hoo, how great is that? Yeah, and I also know that CISM, like critical and stress debriefing doesn't vibe for everybody, which is why we also allow for like individuals to reach out and sometimes what we've done with some calls where like it didn't necessarily impact like the whole crew, but would reach out directly to a provider that was struggling. So it's a resource that is available. Yeah, the reason I asked and brought it up is because I've been unfortunately involved in several severe incidences from fires and car accidents, in multiple roles, whether it was on the fire service side or a cop, the military. So, and I found it just for me to be reasonably helpful. Reasonably helpful. So, I mean, that's what I thought was, I think it, like you said, it's not for everybody, but. Right, right, that's a good point, Stephanie. And thank you, Brandon. Yeah, I think that the, what inside of organizations, sometimes what I'll see happen is even if we don't have like the additional funding stretch, even if we don't have, like sometimes it can be like a really ad hoc, like peer to peer, we work in this space, we're gonna take one 30 minute segment a month and we're gonna have like our lunch together or we're gonna have a call or we're gonna whatever, and we're gonna have this deep, like we're gonna be able to container our stuff because I know that I'm gonna have this time with my peers and I'm gonna be able to sort of like talk this through a little bit, right? And all of those little pieces help. Having someone that you're really connected to, that you make an informal arrangement with, that's like, we're gonna, you know, we're gonna have a buddy system here and I'm like gonna have your back and I know you're gonna have my back and building those out even on an informal, in an informal way are, it's just a tremendous benefit. And again, it's not, people navigate their trauma and heal differently. Knowing yourself, Brandon, is such a great tool to be able to know what kinds of things you can build in that are just gonna, like presume in this work, presume there's gonna be trauma and be like have some spaces to have outlets for it, right? Whatever those, that means for each of you. Finding those outlets are incredibly difficult coming from the service side of this and then trying to speak to, you know, civilians, whether it be, you know, spouses, friends, whatever the case may be who aren't involved in this. I find it, people struggle to wrap their mind around what kind of mental damage and emotional trauma that this causes. I mean, we're fundamentally trying to take care of people while witnessing people in their worst moments. Absolutely. Have to park it and put it away and expect it not to come out at some point. That's going. Yes, and that's exactly my concept around the container that I was talking about. Like if you know that, you know, it's easier to park something when you know that it's shelved for a period of time and then it's going to be dealt with than to try to just turn your back like it never happened and carry on, right? All right, so I'm gonna move us forward because I wanna make sure that we get through the brief negotiated interview here. So our last strategy is the summaries. Great way to make a transition. So you can, in an MI congruent interaction, you might say, okay, let's take a look at what we talked about so far. You're aware that how important it is to take care of your wound. You want the pain to stop. You're afraid you could lose your leg. You plan to make time to follow through with seeking treatment, even though you don't think that you totally trust the competency of the ER. Did I miss anything? And I always like to end those summaries with what did I miss or what did I get wrong or correct the places that I misspoke. Can you add anything, right? Just to make sure that I didn't miss anything and to engage them in that summary part of the conversation. It's a good transition. So we talked a little bit about why we have this brief negotiated interview. MI was built in with the intention that we were gonna see the same person with the same provider and the same client. And then we started to see how valuable MI was and tried it in different settings with different environments, with different health behaviors. And it was efficacy, efficacy, efficacy everywhere. So then we decided to condense it for the first users of the first setting that brief negotiated interview was used in was an emergency room setting, which makes perfect sense, right? Lots of trauma, lots of ambivalence in those spaces around folks that whether they're gonna seek treatment or not seek treatment for the care that they need, not just around substance use, but all sorts of things. And very quick interactions, right? A doctor has a nurse provider, a practitioner has how long with each patient? Minutes. Sound familiar, right? Like often our work is like I have, I'm gonna do a street outreach. I might be walking with my person. They're going to, they might be going to cop and I'm just like sort of walking along with them and having this conversation while they're going, and we have like, I have like three minutes because that's how long the walk is, right? And then that's it. And that's the end of that interaction. What can I do in that time? Okay, so this is a brief negotiated interview algorithm. It's these four parts. And I wanna be clear that while I might have spoken a bit about not trying to sort of overwhelm folks with your expertise, I do wanna make sure that I note that expertise is valuable and there is a place for it and it's gonna go in here. It's gonna get plugged in here with permission, right? Particularly in the opioid epidemic, there is real-time data. I don't know if any of your agencies or your department of health send out like mass spec data. You've got like drug checking devices. That's like real-time data that changes very, very quickly. It's super helpful for our population to know like what's in a particular supply. Also helpful when there's... Do you all see a lot of xylosine in Vermont? I'm not sure what the prevalence is there. So I think according to last year, about a third of our overdose deaths included xylosine in the system. So it's been... So we've been tracking it since I think like 2017 or 2018 with regards to our fatalities. Yeah, and so you're seeing the wounds? Yep. Yeah, okay. So if you've been seeing it for that long, likely many of the folks that use opioids are aware and they can tell you after they use if it was in their supply or not, right? Because they can feel it. But the prevalence, the amount of xylosine, some folks are really actively trying to not use bags with xylosine in it. So this kind of information can be really helpful. We just can't make assumptions I think necessarily about what people are shopping for, right? We don't know. There might be... There are certainly folks in Philadelphia, for example, you couldn't buy a bag of opioids that didn't have xylosine in it, it just doesn't exist anymore, right? There are still markets where you can purchase, where there's diversity in the supply. That is not the case in every drug market. So these pieces of information are not just expertise that we learn as practitioners or clinicians or as EMTs or as nurses, but that we gather in terms of real-time data that can be incredibly valuable. But again, permission, right? Because oftentimes if we give that information in a way that sort of presumes that we know what somebody wants, I mean, think back to the beginning of fentanyl, right? We did these fentanyl test strips assuming that people didn't wanna buy fentanyl. When in fact, how long did it take until like, it was like actively seeking, right? So the xylosine test strips are in the same, right? Would these be helpful to you? Is this something you're trying to avoid? Would be a way to ask that question. Yes, Stephanie. I know we're running short on time. So for our naloxone leave-behind kits that EMS has and our harm reduction packs that many, probably the organizations that are recovery centers and other harm reduction organizations, they do have like a pack of xylosine test strips and fentanyl test strips. It's pretty, and I think with xylosine, we agree don't necessarily know. Philly is one of our source cities, but we have several. So it's probably pretty mixed across the state. But we have seen more like prolonged sedation and we utilize EMS data to do some of those spike alerts as well as emergency department data. And we're increasing drug checking. It looks like there's a couple of people that are doing it actively in their communities. That's great. So the idea is that these are pieces of information that you may have, that you may stay on top of as a provider in this area that you could provide to a client, but they may or may not. I wanna talk about how we provide it, right? How to do that in an MI congruent way. So the engagement piece is we're building rapport. For those of us that are seeing some of the same folks over and over again, we might already have that rapport built. And that's awesome. If we're like early on in this thing, in terms of like a first interaction with someone, then we really wanna try to build that rapport quickly, especially if we're particularly concerned about this individual. Since it's a quick interaction, we are gonna raise the subject. I think back to when we first introduced this curriculum and we had a summit, we had an individual there that we had a panel of folks and on the panel sat someone who went to OnPoint as a client and one of her providers at the drop-in center at the Overdose Prevention Center. And OnPoint is Overdose Prevention Center, which is also called a safe injection site in New York City. We have two of them that are lethal. And he asked her about a wound that he saw and they actually worked together after he had been helping her find a better, they worked together to like find healthier veins for her to inject in and had built a rapport that way over time. And then when he asked her about a wound that he saw, she was able to, she started to respond to that question and then learned how to take care of her own wound. She lived in a car with her husband. She took the information, she helped care for his wounds. They had a real reduction in the impact of their, like a much faster healing journey and I think a reduction in some of the negative impacts that could have happened as a result. But she said she wouldn't have had the conversation if he didn't ask, right? So the power of asking is really important. So something like, hi, I'm Stephanie, I'm an outreach worker with the Bronx Opioid Collective. I noticed you have a bandage that looks like it could benefit from being changed. Are you okay with us talking more about it? They could end this conversation at any time, right? But for the sake of this going through the algorithm, we're gonna assume that they said, okay, this is the part where we provide the expertise. Elicit, provide, elicit, EPI. So elicit permission to provide information. They say, yes, provide it. And then elicit a response based on the information we provided. We're non-confrontational, we're neutral. We're not making assumptions about things. We're zeroing in on main concerns because we don't have a lot of time, right? And we wanna sort of get to the heart of it in a way that's still MI congruent. So would it be okay for us to talk more about it? With the increased prevalence of xylosine in the opioid supply, so severe wounds are causing more sepsis and amputations among people who use drugs. What are your thoughts and concerns related to your wounds? So now we're ending with that open-ended question so that we can have a little bit more of a conversation about understanding what their level of concern is. Evoking the individual's reason for change and reflecting on those. That's the change talk. The readiness ruler. That's the, if you've seen the, on the scale from one to 10, which we'll talk about in a second, and developing discrepancy. I think it was Kimberly gave us a great example of that. And there's one here too. So the readiness ruler is a way to tease out what's on either side of the fence, change talk and sustained talk. So you could say on a scale from one to 10, how likely are you to seek medical care for your wound? And they might say, eh, a four. And I might say, oh, why did you choose a four and not a two? And then that will elicit all the reasons that they are, you know, kind of thinking about it, right? And then they'll, it'll be a sort of a prompt for them to share those reasons. And if I want to know what's keeping them from it, I could say, why'd you choose four and not seven? And then they'll tell me all the, well, if I go to the hospital and I sit there and I wait so long and then I get sick and nobody sees me and then they give me a thing and they never, right? But you might learn something there that's important too, something that we might be able to help bridge like we were talking about the importance of knowing the sustained reasons. And then that just developing discrepancy. So on one hand, you recognize this wound is painful and potentially serious medical concern. And on the other hand, seeking medical care feels like a waste of time given your past experiences. Silence. And just allowing that to settle in and letting the person just sit with that discomfort of like sort of raising that up to the surface. And then lastly, we want to negotiate a plan, right? So we want to develop a collaborative plan. And this is the part where we are going to, you know, if again, they can end the conversation at any time and we are going to be, we are not, we are going to realize that that is not about us. That is absolutely their right to do so. And we want to respond to that. Your response to that is like going to make a difference often in how likely they are to have that conversation again, right? So like if you're sort of able to maintain that neutral compassion, then the likelihood that they're going to come, that they might want to speak to you when they're ready is much higher than if they ended the conversation and they felt like some defensiveness or combativeness from you, right? So exploring some of the challenges, assessing confidence, using that summary, and asking for permission to make the plan. Would you be interested in developing a plan together? While you're, and then the summary, while you're not comfortable going to the hospital, you might be open to checking out the mobile care clinic that comes by on Tuesdays. So take some wound care supplies and do your best to keep your wounds clean and dressed in the meantime. You also felt like it's important to monitor your wounds for pain or color changes, and you might consider seeking additional care if you notice concerning change. Did I capture everything? So how do we know we've been successful? Have we supported their autonomy? Does the individual look engaged? Were we able to stay in that empathetic place? Were we able to stay there without judgment? And most importantly, I ask myself literally every time I have an, you know, I attempt an am I congruent conversation, I ask myself when it's done, would this person speak to me again? And by me, it's, again, I'm not just representing me, I'm representing all the me's, all the you's and all the me's, right? And we can see it when people in our roles haven't treated our folks well, because they are, we see the residual response to that in their interactions with us, right? We wanna be a voice that shifts that, that shifts that paradigm. We wanna have an interaction that shifts that paradigm. And we.

motivational interviewing

medical attention

building rapport

eliciting responses

negotiated interview

open-ended questions

readiness rulers

developing discrepancy

collaborative plan

ongoing communication

supportive interaction