in Managing Pain, which is part of our core curriculum in the area for PC-SSO training. My name is Dr. Patricia Bruckensahl, and I'm an associate professor and a nurse practitioner at Stony Brook University School of Nursing. Today's talk is about motivational interviewing and using it as a tool for support for managing patients with pain and substance use disorders, but it also can be used in many, many different patient situations. Our objectives for this talk are to describe first some of the foundations of motivational interviewing and see how these fit into healthcare. We'll discuss the foundational components of motivational interviewing, and then finally take a minute to apply these skills in a pain management framework. So what is motivational interviewing? Well, motivational interviewing refers to a counseling approach, and it was developed by psychologists William Miller and Stephen Rolnick, and they developed this concept through their work and experience with treatment of problem drinkers. It's a method that works on facilitating and engaging intrinsic motivation within patients in order to change their behaviors, and in that, it's considered a goal-oriented and client-centered counseling style for eliciting behavior change to help patients explore and resolve ambivalence. It's directed in the fact that the counselor or the healthcare professional knows the direction that they want to go, but it's patient-centered in that client's readiness determines where they're going to begin and how fast they're going to proceed, if at all. It's not psychotherapy, it's not a stage of change model, and it's not for every patient in every situation, and we'll explore this a little bit. And the other thing is while we'll go through some skills, it's not easy to obtain competence in this, and so it does require some practice and awareness of what these skills are. And so one of the main goals of motivational interviewing is to really engage patients and eliciting change talk so that they can get the motivation to make positive changes. And so that's really the basis for motivational interviewing. And so why consider motivational interviewing in healthcare? What are the lifestyle management problems that really contribute to poor health in our society? So it's no surprise we know that many, many Americans suffer from chronic pain. Only about 50% of patients take medications as prescribed. There's a large portion of Americans who smoke cigarettes, we're overweight, we don't exercise routinely, eating properly, and also a great portion of the population actually reports not using alcohol consumption in responsible ways. So what about these poor lifestyle habits? What happens? Well, we know that they contribute to mortality and morbidity. They reduce quality of life. Productivity loss is experienced from clients who engage in these behaviors, and of course they contribute to escalating health costs. So it begs the question, if we know all of this, why don't people change? Well I guess there's several reasons we might consider. One is sometimes we think maybe they just don't see it, they're in denial, or they don't know that they have to change. Maybe they don't know how to change, or they don't care. So if we take this approach and think about it, we might say to ourselves, well, if I just give them some insight, if I can make them see, then they'll change. Or if I just give them some more knowledge, maybe then they'll know enough that they have to change their behaviors. If I teach them the skills, maybe then they'll do it. Or maybe if I just make them afraid enough or make them feel bad enough about themselves, they'll change. Well, does that really happen? It turns out that motivation is the central piece to this behavioral change. So think for a minute about the common approach to change that many health care providers and that many of us are used to using. We kind of take this pervasive, persuasion approach. In this approach, the health care provider is the expert, and that's true. We are experts in many things. But just being expert and telling somebody what to do doesn't make them change. So again, think about this, how we currently may approach change, behavior change in patients. What we do as health care providers is often provide an explanation to patients of why they should change. We'll often give them several benefits of what would result if they made those changes. We tend to give them advice how to do it, then we really want to convince them how important it is to change. And in this convincing, we try to get consensus from the patient about the plan. So again, I want you to think for a minute, has this worked for you in eliciting behavior change in your patients? And how do you think patients feel about when we're kind of telling them what to do and why they should change? For most people, they know they should change, but they just are embedded within these behaviors. So what is motivational interviewing, and how might that help in the process of behavior change? So when we use motivational interviewing, in using a nonjudgmental tone and attitudes towards patients, it often helps them to be more open about the pros and cons of their behaviors so they might be better able to process and ultimately resolve this conflict between, I know I should change, but I don't want to change. This is a good reason to change, but I can't because why. And also we know that lasting behavior change can only come through a client-centered approach rather than this provider-directed fashion. So what's a different approach that we might think about? When you think about the role of the healthcare provider as one that understands and collaborates with the patient, the objectives are different than the way we looked at it in the previous slide. So in this particular approach, we want to be able to listen and probe from the patient some reasons that they might want to change. We want to what we call elicit change talk to build motivation for change. We use skills that will ask thought-provoking questions, that will elicit desire, ability, and reasons of why the patient might want to change. Find out what works for them and what doesn't, and then really reflect back and give a short summary to develop a plan of action for patients to behavior change. Now while motivational interviewing is not based on any particular stage of change model, it's often associated with the Prochaska and DiClemente trans-theoretical model for change as you see here on this slide. I think it's important to just have an appreciation of stages of change so you can see where your patient fits within those stages of change while applying skills of motivational interviewing. What this model talks about is that at any given time, individuals might be in any one of a different stage of change on a particular continuum. People move through these stages of change and cycles throughout their life on different issues that they're dealing with. There's some literature that suggests that any given time in the population at large that about 40% of people are in the pre-contemplative stage, there's another 40% that are contemplating behavior change, and about 20% that are preparing for in the action stage change. When we think about the pre-contemplative stage, people who are in this stage are in the stage they're not yet considering change or they may be unwilling or unable to change. The primary task of somebody who is engaged in motivational interviewing for helping patients change is really just to raise awareness or provide some information or explore meanings of events that may be present because of the person's current behavioral style. In the contemplative stage, clients are at the point where they're possibly seeking some help or some consideration for change, but they're still ambivalent and uncertain about how to begin the process and what to do next. Resolving this ambivalence and helping a patient choose to make the change is something that we would really want to work on if a patient is in this stage of change. Then of course, in the action stage, the person is ready and they're committed to change, but they're still considering exactly what to do. Here, in using the skills of motivational interviewing, we help patients identify appropriate change strategies. We might offer a menu of options for change and treatment and then really help them to explore various pros and cons now to the treatment changes that they may have decided would be appropriate or something that they want to do. Again, I just think it's important to recognize that in maintenance, that's the stage where the person has achieved their goals, but we know that relapse is common. Even partial achievement of goals is an important piece to recognize in maintenance and then in helping patients maintain their change. Moving into motivational interviewing itself, there are several principles by which motivational interviewing is based. These principles serve as a guiding framework for choosing the techniques and strategies and skills for MI, which we'll review in a minute. Think about these guiding principles for just a few seconds. The first one is called resisting the writing reflex. What the writing reflex is, and it refers to our tendency to try to actively fix problems in patients' lives. This is something that comes naturally to us as healthcare providers. It comes from our desire to help other people. In doing so, we actually reduce the likelihood that the client will change. The problem with this approach is it doesn't take into account the client's ambivalence to change. We just want to jump in there and fix it. That really is counterproductive to this helping and assisting somebody in behavior change. The second guiding principle of MI is to understand your client's or your patient's motivation. This is a logical extension to the previous comments about ambivalence. We do not motivate clients or instill motivation in them, but rather we find the motivation within them and help them to recognize them. We want to help direct patients towards the discrepancies that exist between what they want and how their behaviors impact these goals. The next principle is listening to your client. Utilizing this principle, you create an atmosphere where clients can safely explore conflict and face the difficult realities of how difficult behavior change really is. We can do this by being empathetic and communicating that empathy to patients. You achieve this through reflective listening and an attitude of acceptance of what the patient is going through. Then finally, or the final guiding principle of MI is to empower patients. We find that outcomes are better when the patient is engaged, and this supports clients' beliefs that they're capable, that they themselves have the ideas for solution, and they can actually enact the change if they decide to do so. Again, those are the guiding principles that are the framework for MI. Next, you want to consider what are the functional components or the stages of MI. If engagement in MI requires healthcare providers to acquire expertise in these eight stages, we'll go through each of these individually. The first stage of MI is considered the spirit of MI. The spirit of MI is the guiding philosophy that informs the principles of MI, the use of the skills and the application of interventions and eliciting this change talk that's so important in utilizing motivational interviewing. Without this special character or spirit of MI, MI is not actually taking place. What is the spirit of MI? Collaboration is the first, and it refers to the healthcare provider acting as a partner with the client. Although we bring expertise to the relationship, the collaborative stance recognizes that patients are experts of themselves. This is really, again, it's a shift from what we may traditionally be used to in practice. Yes, we have a lot of information. That's why we're the expert healthcare providers, but in taking a collaborative stance, we recognize it's really the patient that's the expert of their own ability to change. What we try to do is understand what the client's goals are, and we create a positive environment so the change is possible. It kind of avoids this prescriptive advice that we're commonly used to doing. The second spirit that we talk about in MI is that of evocation. This involves drawing the ideas from the patients and the solutions from them. Our goal is to evoke from patients their reasons and potential methods for change, and to offer ideas for patient consideration if needed. Again, the ideas and the reasons for change have to come from within the patient. Finally, autonomy refers to the fact that decision-making is left up to the patient. We may have opinions that we feel that the patient should take action on, but we must really have the patient recognize that they're ultimately responsible for choosing their own path. Autonomy reflects that they have the right to choose to change or not to change if they don't want to. Again, it's not to say that we may shift into that expert role at times if the patient is engaged in certain really unhealthy behaviors such as misusing or abusing or diverting opioid analgesics, for example. This is a time to shift back into your expert role, but really when we're just talking about behavior change for unhealthy general behaviors, the patient has the right to change or not change. I'm just going to take a minute now to test ourselves from what we've learned so far. In this situation, we really want to start thinking about, is this using the spirit of MI as we've just discussed? Kathy is your patient, and she comes in to see you, and she says, I need to come up with a plan to help me get back on track. This flare-up of pain has thrown me for a loop. What do you think I should do? You, the practitioner, would respond to her, well, I have some ideas about what might help, but first, let me hear what you have already considered. Just take a minute to think, does this response reflect the spirit of MI? I would say, yes, it does. In this vignette, the practitioner avoids the expert role and makes an active attempt to seek collaboration with the patient. In doing so, the healthcare provider doesn't dodge the client's request for help, but ensures that it will occur in the proper context. Again, I've got some ideas, but let me hear what you've already considered first. Also, the healthcare provider does not miss an opportunity to evoke the patient or Kathy's ideas about how to improve the situation. Again, this really is reflective of the spirit of MI that we talked about. The next stage or skill that needs to be considered in this approach is using the mnemonic that we call ORS. This skill development involves acquiring proficiency in the use of classic client-centered counseling skills. In particular, empathy is important here, which includes listening and accurate reflection of what the client has said or the patient has said. How does this mnemonic work? The first one is O. This stands for asking open-ended questions. Commonly, we use closed-ended questions. They are efficient ways to gather information at times, but open-ended questions allow more room for patient response. It invites the patient to say what's important to them. They're really the primary way to elicit what I keep referring to as change talk. For example, you might ask, what are some of your reasons for decreasing carbohydrate intake, for example, if the person had an unhealthy diet? Another open-ended question might be, how might you go about decreasing your drug use? What do you see as some benefits from exercising? All of these are open-ended, and it allows the patient some ability to respond rather than just getting a yes and no answer. The second skill is affirming. Affirmations are statements of appreciation for patients and his or her own strengths. We use these to encourage patients to see their own resources. You need to make these personal and genuine, and even explore partial successes and attempts at intentions to change. They really highlight the patient's attributes and efforts that they've put forth to try to make these changes. An example of an affirmation might simply be, I'm really glad that you decided to come in to see me today. Or something like, you've already come to know and accept some of your limitations due to your back pain, and at the same time, there are some things you'd like to accomplish. Really giving them some positive affirmations on the attempts that they've made. Reflecting is the next one. Reflecting are just simple statements that really relay that you're listening to patients, and you are listening to their needs and concerns. It conveys to them that you're present, and you really see them as an individual, and it is a way to express empathy. Reflective listening really involves paraphrasing patients' comments often. Something like this might be, it sounds as if you're a bit concerned about how to make healthier choices in your life, so you're just reflecting back what the patient has already told you. Again, conveying to the patient, I'm listening to what you're saying. Then finally, summarizing is the final counseling skill, and really summaries are a form of reflective listening and a way of combining multiple reflections in one intervention. It's also helpful to summarize the conversation at various points so that, again, you're checking on your understanding of the patient's position, and it allows for clarity or correction if needed, and again, making sure that the patient understands that he's being heard. Summarizing is also a good way to shift an interaction. If you are allowing the patient to express their concerns and needs and sort of looking at eliciting this change talk, and you've kind of gone through some of that conversation, and now you want to shift the focus to something like the planning stage that we'll get to, you might want to use summarizations at this point to kind of sum up what we've done and then say, so where would you like to go from here, or sort of to the next steps? An example of summaries to restate patient's main points might look something like this. Let me make sure I've heard you correctly. You do want to address your drug usage, and you want information on how to start an exercise program. Is that correct? Then, of course, if the patient responds correct, we move on to some of the next stages. This slide just really goes over some key words to, I think, help us become attuned to to know if we're using open-ended questions versus closed-ended questions. If you hear yourself using these words in your questions, something like, is this okay with you, you're going to get a yes or no answer. Are you willing to make the change now, yes or no? That's a lot different than beginning with open-ended questions, which might look like, how might I help you to come up with a plan? I put this here just to become aware of some of the words that are commonly used in closed-ended questions and where you might want to shift those words to using, including in open-ended questions, to get more of patient's response from that. The next stage, or stage three, in the process of motivational interviewing is being able to recognize and then reinforce what we keep talking about as change talk. It becomes the first step in helping patients to make their arguments for change, when they can recognize change, and helping you to recognize when change talk occurs. If you are engaged with a patient encounter and you start to hear statements that begin with these words, such things as, I really want to change, or I really want to start exercising, you start to begin to hear this change talk. You're starting to have a statement about a preference to change, or a desire to change. They might be talking about their ability to change. I might be able to do that if I got my husband on board, for example. I would probably feel better if I was able to lose some weight. They're starting to give specific arguments about change, or I really should change because this isn't good for me. These types of statements, again, when you're engaged with patient encounters and you start to hear this, you are actually starting to recognize change talk. You really need to be attuned to hearing this so that we can move to the next stage, which is eliciting and strengthening the change talk. Again, when we consider that one of the main components behind motivational interviewing is this idea of developing discrepancy, when we begin to enhance a patient's consciousness of these discrepancies between where they are and where they'd like to go, we are starting to really instigate that awareness for change in a patient. There are several ways or examples to really, again, really start to elicit this and strengthen the change talk if you start to hear those conversations, the talk that patients were having in the previous slide. Let's go through some of these skills that you can use to strengthen change talk. One of the first ones we talk about is the importance ruler. I really think it's one of the most useful tools for eliciting change talk, especially when somebody's motivation is low. Here's how this might work. What you would do is if you ask the patient in a nonjudgmental tone of voice of how important on a scale of 0 to 10, with 0 being not important at all and 10 being extremely important, is it for the patient to feel better about himself by, for example, losing weight, or you could insert any other potential change. When the patient responds with a number above 0, then you might ask, for example, well, that's good. Why did you give that a 4 instead of a 1 or a 2? this again, this is an example of an open-ended question that asks for more elaboration and reasons. And it gives additional insight to the patient's thoughts and feelings. And next you might follow that up with something like, what would it take to raise that four to say a six or a seven? And so this gives the patient some insight into reasons or for plans that they may have to make in order to at least stimulate some more thought or reason for change about this issue. And so I think the importance ruler is a really, really nice tool to use. And later on in this talk, we're gonna talk about applying the ruler in a different situation, which would be to assess confidence in carrying out a plan that somebody might finally make for change. A second skill or way to strengthen change talk is what we call querying for extremes. And so in this particular approach, you would ask somebody, so what are the worst things that could happen if you don't make this change? And again, this is a desired change that the patient came up with. Again, what are the worst things that could happen if you don't make this change? What is the best thing that could happen if you do make this change? Again, you see how these are open-ended. We're eliciting this information from the patient. It gets the patient to think about this, to really look at the pros and the cons, or sort of look at their ambivalence to these change. Another skill you might employ in strengthening this change talk is really looking at their goals and values for this. And so if you would take this approach and say something like, okay, let's for a moment move away from this issue about diet and focus on things that are most important to you, your life streams, your goals, and your values. Tell me about the most important areas to you. And generally, people will come up with things that are involved with their family, their work, maybe spirituality, community. And then you might say, so being here and healthy is important. And how does your behavior fit in with that? And so if you can tie it to sort of this higher value, that may help to strengthen the person to resolve some ambivalence, or really look again at the pros and the cons. You know, they really want to change, but they may have some more insight or motivation to change when they tie it to something higher. And then finally, another way to strengthen this change talk is to actually elicit the negative consequences if they don't change. So you might say to somebody, for example, so what difficulties have you had from taking opioids? Or what do you see happening if you continue to avoid making change in your pain care? And I actually, as a pain management nurse practitioner, I really like that because in taking sort of the old approach or the expert approach when we would prescribe some necessary change, patients will come back and they don't make a change. And so I think to ask somebody to say, well, what do you think's gonna happen if you continue to avoid making change in your pain care? You know, perhaps the patient would say, well, nothing's gonna change. Or I'm gonna continue to feel the same way I do. So again, this eliciting negative consequences is another good skill to have to help strengthen the change talk. And these are just some examples of key questions that, again, you might use in trying to elicit and then strengthen this change talk. So what do you think you might wanna do about it? What does this mean about your pain treatment if you don't make the change? You know, what do you think has to change in order to feel better? So again, these are just some examples. And when I talked about in the beginning of this discussion, utilizing motivational interviewing or engaging in motivational interviewing, it's not simple and it takes practice. So I encourage you to think about some of these questions and approaches to patients and practicing them with patients. Get used to using this style of interaction with your patients. Stage five, I think, is an interesting one and it's important. We call this rolling with resistance. And so, you know, it's one thing to evoke or reinforce change talk, which we've been previously talking about, but how do you respond when resistance emerges, right? And so we call this rolling with resistance rather than opposing it. You wanna avoid the resistance because you don't wanna evoke resistance. So by getting into that sort of match with somebody, you're actually gonna provoke more resistance. So what you wanna do is demonstrate understanding of the situation by establishing rapport and demonstrating, again, you understand the patient's resistance. You avoid pushing against what, you know, pushing against them, which again would magnify the resistance. And so the most common strategies are really very simple and might use double-sided reflection. Something like, I understand your worries about the side effects of your medications. Let's spend some time discussing this. So again, if the person kind of says, yeah, I can't, you know, but I have these side effects to the medication, but I still wanna use them. Okay, I get it. Let's spend some time discussing it. You know, you don't care about your pain medication use, but how does this impact your partner? So again, you wanna just sort of roll with them the resisting of the change. And, you know, some, again, this double-sided reflection. How can I help you move towards making the positive change? What's needed? But don't go back at them with that. Again, you wanna use reflective listening. And here's another example. It's not easy to make all these changes. You think you might not wanna take so much pain medication anymore. And so give the patient a chance to respond. And on the other hand, you said that these medications help you and you don't know how you could live without them. So you're not, you're just going with what they have to say. The next stage along motivational interviewing is really getting to the part of developing a change plan. So again, you've spent the time kind of, you know, being reflective, using open-ended questions, recognizing this change talk and eliciting their pros and cons to change and trying to resolve some of this ambivalence. But there comes a point where you need to attempt to transition from this change talk to actual change. And so this is the time where we wanna really start exploring how the patient envisions change happening and what the patient can contribute to make the change happen. And you wanna do this again without provoking resistance. And so remember back to the MI principle, the patient decides which goals are important to them. We don't decide what goals are important to them. We may use our expertise for sorting out options to find out what the client has considered, right? And it may be helpful to have the patient brainstorm. Or if the patient is agreeable, you can provide a menu of options. Okay, and one of the, another way to do this in developing this plan is to elicit what they know or the elicit, provide elicit technique. And I'll go over that in just a minute. Okay, so again, we wanna transition now. So you might wanna use the technique of summarizing and sort of say, okay, now what would you like to see change? If things were better, what would be different? And so we're moving into this stage of developing the plan. What are some possible options to accomplish this? And again, let them brainstorm. And if they don't know, you might be able to give them some information about what other patients you have in similar situations have used successfully. Now, I mentioned this elicit, provide elicit technique. And so in this technique, you wanna find out what the patient already knows and then you fill in the gaps. And so one way to do this is you might say, well, Mrs. Gold, what is it that you already know about relaxation techniques and controlled breathing and how they help to manage pain and stress? And so you give the patient some time to respond and reflect, you know, respond to that. And then you reflect back, that's great. You seem to know a lot about how stress affects your pain level. I'd like to tell you about the role that relaxation and breathing techniques can play. Is that okay with you? And so you elicited what they knew. No, you provide some information. Here, you're kind of shifting back into your expert role a little bit. And now you shift back into the MI or eliciting from the patient. What do you think makes sense for you right now? What are you willing to do? This is the technique that I talked about with providing a menu of options for patients. And so it avoids this kind of yeah, but dance that typically happens when we start to give advice to patients. So in this example, we have, you might say to a patient, so Mr. Popper, you want to start exercising but you just don't know how to get started. Would you be interested in hearing about some tips that have helped other patients? And then again, you want the patient to give consent because they have the right to listen to those suggestions or not. And then if they give consent, you can give a couple of brief ideas and then say to them of these options or another one that you can think of, which one do you think might be helpful for you? So they're going to pick the option that best works for them. And I think, again, when we're making plans for behavior change, not we, when the patient is making plans for behavior change, even small changes are important and they're probably more important, small steps towards change. And so the final step in this is consolidating what we call consolidating client commitment. So have the patient make a plan. What are they going to do? When are they going to do it? And you want to summarize that plan. And then you want to get a commitment statement from the patient. So actually having them verbalize the commitment to the intention enhances the likelihood that the behavior will change. So after you summarize the plan and say, is that what you'd like to do? Can you repeat back to me what you'd like to do? So again, it's this sort of verbal commitment that the patient has to this. And then we go back to that ruler, the assessing for confidence. So using the ruler scale again, assess for confidence to ask the person on a scale of zero to 10, with zero being not confident at all and 10 being completely confident, how confident are you that you can commit to the plan? And so in using this strategy for assessing for confidence to the plan, it turns out that if somebody responds anything on the ruler from seven or above, the likelihood that they will engage in that plan is a lot higher than if it's below seven. And so again, using the same technique we used prior to that, prior to, when we used the ruler prior, if somebody answers something like, well, I would say my confidence level is about a four in carrying out this plan. You would wanna then say to the person, wow, well, a four is really good. It's better than a one or a two, but what would you need to do to get that level of confidence of doing the plan a little bit higher, say to a seven or maybe even an eight? And so they might need to adjust the plan. The plan might've been too ambitious to begin with. They didn't set the right time to do the plan, whatever it is they wanted to do. So have them adjust the plan. And then again, reaffirm that this is the plan that they're gonna do. And then finally, as healthcare providers, we have to have a mechanism to follow up to see if they have actually engaged in the plan. And so that method of follow-up can be the next visit that you see the patient. As long as you know what you have documented or you know what the patient's plan was, you wanna follow up. You might wanna call the patient. You might wanna have the patient type into your electronic communication system with the patient and just check in and see how they're doing with the plan. And the final stage, again, is really recognizing when it's appropriate to switch between MI and other counseling methods. So motivational interviewing was never meant to be the only tool in healthcare providers' toolkits. It's really developed to help patients through the motivational obstacles to change. So again, as we talked about in the beginning of this discussion, that there are different options, there are different times when we have to use our expertise, but when we think about how behaviors affect people's health in general, the only way people to move towards healthy behaviors is to utilize the skills of motivational interviewing. So that's the purpose for using it. We talked about times when you need to fill in the gaps of patients' knowledge because they really just may not know enough. And so, again, MI wouldn't be used at those particular points. And actually, patients who are really, truly ready for change may not need MI. They're ready for change. They have a plan. They're already motivated. And so it's perfectly appropriate to shift between styles when necessary. But again, in the spirit of MI, collaboration and respect should always be part of patient-practitioner relationships. So I want to just talk a few minutes specifically to look at the use of motivational interviewing in pain management and applying these particular skills. And so we know that pain is prevalent. We've talked about conventional methods of pain management only provide partial symptom relief. And some of the approaches that we're currently taking are not always effective. Pain is associated with symptoms that are modifiable by behavior. And of course, the biopsychosocial approach is one that has always been underpinning an approach to pain management. And so anything that we can do to improve function and enhance the use of self-management skills for people with pain can be very, very effective. And so utilization of MI is a technique that can help to move somebody towards behavior change. These are just some symptoms that we know that are associated with pain. Of course, stress, anxiety, sleep problems, physical limitations, fatigue. And that engaging in healthy behaviors, some of these things listed on the other side of the slide might help to alleviate some of those symptoms. And so again, in trying to get patients to elicit the need for change and the pros and cons to change, these are some of the things that they may come up with, or you might suggest to patients, again, with their consent that may be helpful to patients for behavior change. Here is just a list of some of the literature that supports the use of MI in a variety of painful conditions. MI has been successfully used with community-dwelling elders with chronic pain. It's been used as a coaching technique to help patients who have pain related to cancer. And also it's been used for patients with fibromyalgia. So there is an evidence-based support the use of motivational interviewing techniques for persons with pain. And then finally, I wanna just finish up to see, use a case vignette to apply some of the techniques that we've talked about. So consider Susan, who's a 58-year-old patient in the pain management clinic. And she's worked as a nurse for 20 years, but stopped 10 years ago due to low back pain. She's overweight, she has arthritis. She's currently been prescribed hydrocodone for the past 10 years. She doesn't think it's helping her any longer. And she says her goal is to taper off of opioids and become more active to play with her grandchildren and go on more trips with her husband. Okay, so sounds like a very typical patient we might see in our pain clinics or in our primary care practices. So when you further explore her goal of tapering off opioids, she expresses concern about her pain management, what will happen when those medications are fully tapered. And she also explains that she's angry about the loss of her physical health and her livelihood, and she feels that life is unfair. So, in considering applying the principles of MI, here are some things to sort of summarize what we've talked about. So one of the things that you might want to think about based on that vignette is what stage of change is the client in? And so I would say that this client has expressed some motivation and some action in her life, yet she's also blocked when it comes to her target behavior and taking the next step. So if you were to apply the trans-theoretical model, the one that we used earlier in this talk, I would say that she's probably in the contemplative stage, that she sees the possibility of change, but she's still ambivalent about it. So the next skill you might think about is how can you use the ORS technique in this particular situation? And so you might approach this by saying something like, I think it's great that you want to participate in more activities with your family. It sounds like they're really important to you. And so here we're affirming what this patient has already said. And then you might say something like, how are the medications affecting your ability to do this or to achieve this goal? And so you're using an open-ended question. All right, okay, so you want to stop taking opioids, but you're afraid that your pain won't be controlled. And you want to be more active with your grandchildren and husband. Is that correct? And so here we've looked at, we're reflecting and we're summarizing. So you've used the ORS mnemonic in that situation. So were you able to recognize the ambivalence to change in this situation? So her ambivalence statement was when something like she wanted to get off her medications, but she was afraid how her pain would be controlled. Okay, so here you can see the ambivalence. And so now you want to elicit and strengthen the change talk. And there's several ways to do this as we talked about earlier. So you might ask her, what do you think will happen if you don't make this change? And so that technique would be again, eliciting negative consequences. Or you might say something like, on a scale of zero to 10, how important is it for you to make this change? And so then that's using this scaling for importance for the ruler approach. What other counseling methods that we talked about in MI might you need to use? And so one thing you might consider doing is utilizing that elicit provide elicit technique. And so to do this, you might say to her, Susan, what do you know about other ways that did not include medication to control your pain? So you were listening from her what she already knows. And then let's just say she gives an answer, we're reflecting back. Yup, hot and cold packs work great for many people. There are other techniques that have worked for other people as well with your condition, such as relaxation techniques and controlled breathing. Can I tell you more about them? And so now you provided some information and you're asking her permission to provide that. And then finally, you might end with something like, okay, of these, which of these do you think might be of interest to you? So again, now you're back to eliciting. So this elicit provide elicit approach. The next thing you wanna do is develop a change plan. And so in order to do this, you might say to her, what would be different for you if we could find another way to control your pain? And so we're looking at goal setting. How do you think you would accomplish, you would like to accomplish this? And so now she's gonna be sorting out her options. And then how specifically do you wanna do this? How do you wanna make the plan? And again, you wanna make sure that this plan is what we call a SMART plan, right? It's specific, it's measurable, it's achievable, it's realistic, and it's timely. And then finally, you need to, or you wanna elicit the commitment statement from the person. And so you wanna make sure you check back with her, so does this sound good for you? And let her verbally commit that this is the plan that she wants to do, and then rate her confidence in accomplishing this. So again, on a scale of zero to 10, how confident are you that you can accomplish this? And then again, just to review, seven or above in confidence is good to go. Below a seven, you might wanna, you know, help her to adjust that plan to make sure that it's more achievable and doable. So just again, in summary, what we've gone over are several techniques that are used in motivational interviewing. We talked about the core components of motivational interviewing. And then again, we started with the foundation or the spirit of MI, which is that collaborative approach between the healthcare provider and the patient, evoking the change and the plans from the patient, and recognizing that the patient has autonomy to change or not change. Again, to just affirm that this has been a whirlwind sort of tour of MI. It does take practice, but I would encourage you to think about some of the skills that we talked about and just start to, you know, embed those in your encounters with patients and get more comfortable and more familiar with this style of having a conversation with your patients to, you know, hopefully with the goal of improving their pain management in general. So again, client-centered philosophy, non-judgmental tone and attitudes, focuses on what stage the client is at. And then finally, again, even if the patient does not choose to change, the intervention is not a failure. Any discussion or talk about change is actually planting the seed. And you can always go back to this on the next visit, on the next encounter. Some references are provided for you here. And then finally, again, I wanna thank you for listening to this webinar. This particular slide provides you some information about the PCSSO Mentoring Program, where we offer colleague support with one-to-one discussions on specific topics on opioid use disorder and pain management. We also have some information at the bottom of this slide about a listserv, which also allows you to work with mentors. You can post questions on this particular listserv, and then experts from the team will get back to you with answers on your questions. And then finally, this slide lists the consortium of partners that are involved with the PCSSO Training Program. Again, thank you so much for listening to this webinar.

motivational interviewing

Dr. Patricia Bruckensahl

Stony Brook University School of Nursing

pain management

substance use disorders

client-centered counseling

behavior change

healthcare

MI techniques