<v ->Hello, everybody, my name is Joji Suzuki.</v> I'm the director of the Division of Addiction Psychiatry at Brigham and Women's Hospital, I'm an Assistant Professor of Psychiatry at Harvard Medical School, and also a member of the Motivational Interviewing Network of Trainers. I'm here today to present about the principles of motivational interviewing, which should be useful for primary care providers. I have no relevant financial disclosures, and this is the target audience. The objectives for today are to describe the spirit of motivational interviewing and the four processes, utilizing patient-centered motivational interviewing skills to help elicit and strengthen internal motivational change, and then finally, how to summarize the plan for change in a MI-consistent fashion. So this is where we start. We as healthcare providers engage in discussions about behavior change all the time. In fact, when it comes to treating opioid use disorders, obviously that's a big part of what we're trying to accomplish, is helping patients change their behavior, whether it's opioid use, other substance use, other lifestyle behaviors, et cetera. And these encounters where we're recommending some type of a behavior change, can sometimes lead to an argument. And what I mean by that is we're recommending some kind of change, whether it's taking medications, stopping or using substances, or engaging in treatment, therapy, whatever you have it there. The patient may say yes but no, sort of decline it, or reject it, or refuse to engage in that change. And so what we as clinicians can sometimes end up doing is entrenching in the position of arguing for change, and then patients may get stuck in their position of arguing against it. And so the basic dynamic, it's some version of we're recommending change, and here we're saying you need to stop smoking, patient says something like," Yes, I know, but." And comes up with some excuse or reason why, why not? We, again, further entrench in our position of arguing for change and then the patient further entrenched in their position. So the basic thing that gets repeated is, we're recommending change and the patient says yes, but no. So when this happens, I've asked this to many, many clinicians over the years, how does that make you feel when these discussions about behavior change turn into this type of an argument? And basically it makes us feel like we're not being helpful, it's frustrating, it makes you feel powerless, it feels like a waste of time, I feel incompetent. But basically it's not enjoyable having this kind of conversation where we're recommending something for them to be healthier and they're rejecting it. And of course, there are times when clinicians are made to feel like they don't want to be so paternalistic with the patients. So bottom line is, what motivational interviewing can do is that hopefully learning the skill can help you feel less frustrated having these conversations about behavior change, but also just as important is be more effective in helping patients change. And it'd be nice if you can accomplish these two goals by learning the skill. So what is motivational interviewing? It's really a guiding style of communication where you pay a lot of attention to the language of change, and then you're evoking the patient's own reasons for change. And this is really the basic definition of what motivational interviewing is. And so whatever you're doing, if this is actually what's happening where you're evoking the patient's reasons, own reasons for change, where you're focusing on their language of change, then you're doing some version of motivational interviewing. It's also important to point out what motivational interviewing is not. It's not psychotherapy, it can be done in the context of psychotherapy, but really again, it's simply a style of communication with another human being. And so what's nice about that is that it can be incorporated into what you do day to day with your patients. Whether it's a simple office visit around a new patient visit or a particular follow up visit where you're focused on medications for diabetes, or again, whether in the context of treating opioid use disorder, it can be easily incorporated into what you already do. So it's not, should be thought of it as a standalone psychotherapy. It's also not the same as stages change model, which is I think, familiar to most clinicians. It's a useful model, the nomenclature can be very helpful, but as a clinical method, stage of change model actually has not been particularly successful. Motivational interviewing is the opposite, it is actually a clinical method that's been studied repeatedly and it's based on research, and it has robust empirical support. Motivational interviewing also is not decisional balance where you're doing pros and cons. It can be done in a context of motivational interviewing, but on its own, doing a decisional balance actually can further entrench the ambivalence. So on its own has to be used with very particular intention, but it's simply, again, doing the pros and cons is not the same as motivational interviewing. Also, motivational interviewing is not for every patient in every situation. There are certain times when it's appropriate and other times when it's not. It's one tool out of the many tools that you utilize in your patient care. And finally, this is what's most frustrating for me as a trainer is that it does take a lot of practice to get better. But every time you talk to a patient about behavior change in a way you're practicing, so you should have plenty of opportunities to practice this skill. What is the evidence-base? I mentioned there's robust empirical support. At this point there's been hundreds of randomized trials for all kinds of target behaviors, whether it's substance use, medication adherence for other chronic diseases, et cetera. This is a example of the type of literature that's out there. This is a systematic review of review papers, and so this includes 104 reviews and 39 meta-analyses. So again, there's a tremendous amount of empirical data in support of motivational interviewing in proving clinical outcomes. And so what this concluded is that there's moderate quality evidence for mainly short term, statistically significant beneficial effects in particular, and we don't know exactly why, but motivational interviewing has a particular impact on substance use outcomes, potentially because of the stigma associated with the use, et cetera. But regardless, this is a reason why we strongly recommend incorporating motivational interviewing skills into the practice of treating substance use disorders. In the practice of motivational interviewing, the first place we usually start is talking about what's called the spirit of MI. And everything that follows essentially flows from this. And as long as you're embodying these ideas, you're doing, again, some version of motivational interviewing. And so the spirit of motivational interviewing includes acceptance, partnership, evocation, and compassion. And we can spend a lot of time talking about these, but very, very quickly, acceptance is the idea that we should accept the patients for who they are. And embedded within that are two key concepts that are very important in motivational interviewing. One is respecting patient autonomy, and the flip side of that is demonstrating accurate empathy. One of the common themes in motivational interviewing is the idea that we should really honor patients own decision making abilities, their internal method of control, their own reasons for change, and respecting their decisions, or their ability to make the choices that they want to make, by this is in a way the paradox of behavior change, the more we're able to honor patient autonomy in a way patients actually are more willing to listen to us. But what goes along with the respect for autonomy is the idea, again, I said that accurate empathy. If we're not truly able to demonstrate that we understand the other, it's actually hard to truly honor their autonomy. And so these two concepts are probably very important ideas embedded within this idea of acceptance, respecting autonomy, and demonstrating accurate empathy. Partnership is the idea that we should approach behavior change conversations as equal partners. As healthcare providers, we are trained extensively in the diagnosis, the disease process, the pathophysiology, the practice guidelines, and all that stuff, we learn, and we spend many years in school, and training to acquire those skills and knowledge. Many times our interactions with our patients, we adopt a expert and a novice relationship. And there are times when that's appropriate. But when it comes to behavior change, especially in the context of chronic disease treatment, it's better to adopt this partnership as equal experts. We're the experts on the disease and the treatment, et cetera, but patients actually have to become the experts on implementing those changes. So for example, if somebody wants to quit smoking, we can't do it for them, patients have to do it themselves. So in that regard, they have to become the experts on how to actually do it and how to actually implement it. And so it's a coming together of experts. Evocation I've already alluded to the idea that in motivational interviewing our goal is to try to evoke from the patient their own reasons for change. I have my own reasons for why I might stop using, or not ever use heroin, or fentanyl, or cocaine, et cetera, but that's actually not that important, what's important is why the patient, him or herself, may choose not to use, or cut back, or change behavior. And finally, compassion is the idea that we should be doing this for the benefit of the patient, and that's, I think that's pretty obvious. Now I think all listeners to this will, I think agree to this, I don't think anybody here will disagree that these are important concepts, but in motivational interviewing what we try to focus on is that we need to be able to actually demonstrate this through our behavior. So I'll be talking more about how we actually do that in motivational interviewing. The second key idea in motivational interviewing in the, at least in the current iteration of it, is this idea called the four processes. It's the idea that all four of these should be done to some degree, not necessarily every single time, but in each encounter, which could be a two minute encounter where you're doing motivational interviewing for two minutes or iteratively over multiple visits, over many encounters. It's important to keep these four processes in mind, and it's not meant to be a stepwise process necessarily, but I think it's important to always keep in mind these four processes because they all support each other. And the first place is, it's called engaging, where it's reinforcing the idea that motivational interviewing occurs in the context of our relationship. Again, this is where things diverge from the stage of change model, where the focus of behavior change is entirely focused on the patient, him or herself. Motivational interviewing specifically includes us as the provider or the clinician, and it's a relationship between us and the patient that's actually the basis for behavior change. Focusing is the idea that we need to always ensure that the agendas that we bring to the encounter and the agenda that the patients bring to the encounter are aligned. Because when they're not aligned, actually that can really be inefficient and doesn't support our behavior change discussions. Evoking as the heart of motivational interviewing where this is where we're trying to strengthen and increase the motivation for change. And finally, planning is the idea that we should somehow translate that increase in motivation into some change. So all these four processes, I'll be talking more in detail and how they work together in helping to increase motivation. But one thing to highlight is that there really should be no fantasy that just because you have this conversation over two minutes, five minutes, ten minutes is going to change behavior. It generally has to be done iteratively over many encounters. But again, the evidence base does strongly support that doing this even in a brief moment can have a clinically significant change in outcomes. So let's start with engaging, talk a little bit more about this relational foundation, just very quickly, one of the suggestions in terms of how do you open up this conversation about substance use, here are some suggestions and I'm sure everyone here has their own way of opening up the conversation, but I like this one about asking permission. "Would it be okay if you spend a few minutes talking about X?" Because asking permission tends to lower our patients defenses because they are actually allowing you to come in the door, so to speak. Or you can simply ask, tell me more, and these open ended questions where you're asking, "Tell me more about how this fits into your life." Or you can do a, "What's good about heroin or what's not so good?" So these are all different strategies, do what you like to do. But the point here is that, as clinicians there's a tendency to immediately go into giving recommendation, giving advice, giving warnings, et cetera. Those may be warranted, those may be important things to do, but I think too often we go there too quickly. When we do that, the problem is that, that can actually backfire because that can actually push the patients to the other side of the ambivalence, and I'll be talking about this idea of the ambivalence. During this engagement phase, one of the things we recommend is for clinicians to be using as much as possible what we call the OARS skills, open-ended questions, reflections, affirmations, and summaries. And these are all strategies that we think are actually help to evoke more information from the patient, it conveys our willingness to listen, that we're not going to immediately assert our agenda, and engage in the writing reflex. It really helps to open up the dialogue and increase the rapport. And really, I mentioned the importance of empathy, but during the engagement phase is really the time to demonstrate not only that we're going to listen, but that we understand. Of course, in medical school, I learned how to give empathic statements, these are some of the things that I was recommending, "I know how you must feel." Or, "It must have been difficult for you." Now these aren't bad, it's just that they don't actually necessarily demonstrate empathy, and so, what we recommend is reflective listening. And so among the OARS skills, essentially the ARS affirmations, reflections and summaries are all versions of reflective listening. And for that reason, we would consider reflective listening, probably the most important skill in motivational interviewing. And indeed, if you're not using any reflective listening, it's hard to actually be doing good motivational interviewing, it's that important. And so the basic idea is that the patient thinks to say something, they say it, we hear it, we try to interpret it, and reflective listening is to then reflect what you think the patient said back as a statement. And there's two basic types of reflective listening, reflect statements, simple and complex. Simple reflections are, as a name applies simple, because they stay close to what the patient said, at least on the surface, so if a patient said something like, "I need to stop using cocaine." Very easy, simple reflection would be something like, "You want to stop using cocaine." That would be a pretty easy one. Now in this situation, I think everybody can agree that I just conveyed that I understand, but I didn't say, my response wasn't, I understand. It's reflecting back what I heard, and my words demonstrate that I understood. Now the depth of the understanding is pretty limited with a simple reflection of course. Let's see another example. "My drinking is not a problem." And the simple statement reflecting reflection back might be "Your drinking is not a problem, okay." But the point of reflective listening is that we are demonstrating through our behaviors that we understand. And the goal of doing reflective listening in motivational interviewing is not to simply parrot back, simple reflections, it would actually be very annoying if that's all you did. The goal in motivational interviewing is to utilize what we call complex reflections, which the technical definition might be to add substantial meaning. And what I mean by that is we're trying to actually make these hypotheses about what the patient's trying to convey or communicate, and what's underneath what's being said. So here's an example. If a patient says, "I want to stop drinking." A complex reflection might be something like, "Your recent DUI was a wake up call." So that's not what she said, you're making a guess. Now what's interesting about complex reflections is that the only way you can do this is by listening, because if you're not listening, it's really hard to actually do this. But what's more important is that as long as you're in this interpersonal space that I discussed earlier in terms of the spirit of motivational interviewing, acceptance, respect for autonomy, empathy, partnership, evocation, et cetera, the patient experiences these complex reflective statements as your genuine attempt to try to understand. And so if your statement was correct or near the truth, the patient will respond with some version of yeah, and keep talking about it, attempts to evoke more of what you're saying. If you're on the other hand wrong, or it's not correct, or it's far from the truth, what's really interesting is that, some patients may get offended, but that's actually not the common type of response at all. In fact, patients will respond by saying, "Well, no, no, that's not what I meant, what I meant to say was." And actually help clarify what is it that they're trying to communicate. Again, as long as you're listening, and you're conveying empathy, and being non-judgmental, not asserting your agenda, respect the autonomy, patients actually help you understand better. And so the end result is whether you're right or wrong, there's a deeper sense of understanding, and greater sense of empathy. And this is exactly why reflective listening is such an important tool and a skill in conveying empathy and part of motivational interviewing. So here's another example of a complex reflection, "I think I need help, I want to stop using heroin." So complex reflection might be something like, "You're afraid what would happen if you keep using, and you realize you can't do this on your own." One of the tricks is to incorporate some kind of affect, or emotional content, reflecting that back. So here afraid is an easy way to add complexity to the reflective statement. Let's see more examples. "I shouldn't be snorting percocets anymore." "On the one hand, the pills make you feel normal, and on the other hand you realize you could overdose any day." This is the type of complex reflection we call double sided reflection, where the first part of the statement is aligning with what I'll talk about shortly is the sustain talk, the part of the patient that wants to continue this behavior, so taking pills make her feel normal, but on the other hand, the other side of the ambivalence, the side of the patient that wants to change, that the patient realizes doing this is really dangerous, and then that could cause an overdose. And so this is a type of a double sided reflection where the ambivalence the patient has about the behavior is being reflected back. So these are all different ways of doing complex reflections. It does take practice. Again, as I mentioned, it's probably the single most important skill in motivational interviewing because it helps to demonstrate that you're going to listen, that you understand, that you're not going to judge, that you're not going to immediately try to fix things by engaging in the righting reflex. And so the goal again, is to use more complex than simple reflections. It's not that simple as bad though, I think it's very important to convey that both can be very, very important, and simple reflections can be powerful statements to make, but the goal is to use more complex than simple reflections. Okay, so that's the engagement piece of the processes. And as a rule of thumb, what one thing we try to recommend is whatever the duration of the encounter you're utilizing to do this motivational interviewing is to maybe spend 20% of the time just focus on engagement. Because in a way it's investment in the interpersonal context that supports the spirit of MI that I've been talking about. Because without that, actually it's hard to get to the other parts of this interview. Focusing is the idea that, as I mentioned, it's really aligning the agendas, it's agreeing what to talk about because sometimes in clinical encounters the focus is clear, other times there are several options, there are times when there's no clear path. When I do a counseling supportive session, and initially there's really no clear path at all that may be the case with a new patient, for example. But when it's a follow up visit for buprenorphine, then maybe the focus is much more clear. But typically there are several options to discuss, it could be about the medication, it could be about this other struggle that they're having with their diet or exercise, or other illnesses. And so, all I'm going to say here today for purpose of today is to say that there's some time that may need to be spent to ensure that you're talking about the same target behavior, okay? So let's move on to the heart of motivational interviewing, the evoking phase. And the imagery that I like to always utilize is this hill that keeps going upwards. And the basic idea is that the height of the hill represents the strength of the patient's motivation to engage in behavior change. So many times we're talking to patients who are at the bottom of the hill because their motivation for changing isn't that strong. And so, you may have heard the term motivational interviewing is about meeting where the patient is at. And that's true, our goal is to engage with the patient where they're at, to understand where they're, accepting them, again, the acceptance idea, and that we're going to work with them. But the important thing to recognize is that in motivational interviewing, the goal is not to simply engage with them where they are because they haven't changed yet. Our goal is to actually meet them where they would prefer to be, where they would like to be, where they aspire to be, where they dream to be. That's where we're want to help guide our patients to be. And so the the assumption here is that patients who are not really changing yet, or have a low level of motivation, but the goal is to help increase this over time. And at some point, our hope is that the strength of the motivation is strong enough that the patient will engage in change. What this means is any movement up this hill is a good thing. It'd be nice if we can just talk to a patient for five minutes and they're where they need to be. But in reality for chronic disease management, including treating substance use disorders, is that it's going to take time. And so it's okay, even if a brief conversation leads to a slight increase in motivation, because the hope is that you'll do that iteratively over many encounters. So how do we do that? So the basic idea is that in clinical encounters we tend to utilize external ways of motivating patients. These include things like giving advice, giving feedback, trying to persuade the patient, warning the patient, sometimes using maybe course of strategies, in extreme cases for example. I'm a psychiatrist and when I work in the emergency room, I might have to commit the patient involuntarily to the treatment against their will, and that's probably the most extreme form of external motivation. So there are times when externally driven motivations to change behavior can be very important, in fact, sometimes mandated. But when it comes to treating patients with substance abuse disorders or other chronic diseases, ultimately the change has to come from within. Smoking on an airplane is illegal, so you don't really see people lighting up, but then as soon as they get off the plane, they're going to be lighting up a cigarette, so external motivations can work quite nicely for the short term, but if you want sustained behavior change, ultimately we need some change in internal motivation for change. And so, but with internal motivation, you can't really directly see it, directly measure it, one of the ways in which we can get a glimpse of it is using this idea called the ambivalent. And this is one of the assumptions in motivation, but I think it's a very important one. It's the idea that the vast majority of patients who are engaging in unhealthy behaviors are ambivalent to some degree. Ambivalent doesn't have to mean that it's 50/50 split. A smoker doesn't have to be 50% on the side of want to keep smoking, and 50% on the side of want to quit. It might be 1% and 99%, it could really vary, but the point is the vast majority of patients have some ambivalence. And it's pretty rare to have a patient who has zero desire to change at all. Now those patients I'm sure exist, but most patients that we engage in clinical situations have some degree of ambivalence. The side of the patient that wants to change, we call Change Talk. The side of the patient that doesn't want to change, we call Sustain Talk. And sustain is sustain the status quo, and that's where it comes from. The person in a way inside is split into two sides at the same time. And this is not pathological, this is actually pretty normal thing that we see, and I'm sure this is true for all of you around, most behaviors you engage in, most decisions you make, major and minor decisions, there's some degree of flexibility in a way, and this is considered actually healthy and this is true for unhealthy behaviors as well. Now we as clinicians tend to argue for change when we're recommending behavior change because this is what we normally do. You should take, you have an opioid use disorder, so you should take buprenorphine, makes sense. But if they're ambivalent about it, there's a tendency to push people to the other side. So, we argue for change and there's a tendency for the patient to want to reject it. And again, this is true in ourselves, I'm assuming all of you have the experience of you agree with the recommendation, but because it's being forced on you, or being pushed on you, that you have this desire and a tendency to want to reject it. This is normal, this is normal human tendencies, and actually begins to emerge at age two. So this is the Erik Erikson's stage of autonomy and shame where we build, develop this desire to assert our own autonomy. And so as I mentioned earlier, one of the key concepts in motivational interviewing is to respect patient autonomy, and this is exactly the reason why. We already know that this is our tendency both in ourselves and our patients. If we push too hard, there's a tendency for patients to try to want to reject it. So the goal in motivational interviewing is not for us to argue for change, but instead we want patients themselves to argue for change themselves. And this is what we term evoking change talk, and this is at the heart of the evoking phase in motivational interviewing, is that our goal is to not argue for change, but to evoke change talk, this is the critical task during the evoking phase. So first of all, what is change talk, what are you trying to evoke? This isn't mnemonic you don't have to memorize this, but it just helps to categorize a different change talk. And it's called DARN-CAT, desire, ability, reason, need, commitment, activating, and steps taken already. And so these are all utterances made by the patient that suggests movement towards change. So things like, "I want to quit drinking." "I could cut back on how much heroin I use if I started methadone." "I want to get into treatment because I don't want to overdose." "I really should go to counseling because it really helped me last time." So these are all phrases and language that indicates movement towards change. What's important to point out here is that it's not the words themselves, you can't just tell a patient to repeat a hundred times, "I want to stop using opioids." Just say that a hundred times, and you'll be motivated, no, unfortunately that doesn't work, I wish it did. But these are words that are generated from within and it's a reflection of what's happening inside. It turns out sustain talk is exact the same language, but in the opposite direction. "I want to continue using heroin." Will be a strong desire sustain talk. So the emergence of change talk, actually, there's data to suggest that it predicts behavior change. This is a study from Project MATCH, basically what they did was patients received different type of psychotherapy to address their drinking. What they did in this study is to count the time the change talk, or sustain talk, emerged during the encounter, and try to correlate that with drinking outcomes one year later, as well as absent days. And what this study was able to demonstrate is that what people said, i.e. change talk or sustain talk actually was a decent predictor of what happened afterwards. And change talk was better at predicting improving behaviors and sustain talk was better at predicting worsening of behaviors. And so the part of the model we're trying to build here is that we want to get more change talk because that's predictive of more change that we want to see, and more sustained talk emerging during the encounter is actually less predictive of the change that we'd like to see. But there's another part that's important, which is that if we behave in ways that are consistent with the principles of motivational interviewing that I'm talking about right now, that has an impact on whether change talk or sustain talk will emerge. So what the researchers did this time is that they actually looked at the therapist behavior, and coded them to be whether they're consistent with the MI principles or not, and they want to see what type of language change talk or sustain talk emerged immediately afterwards. What they're able to demonstrate is that after behaviors that are consistent with the motivational interviewing principles, the likely to have change talk emerging, actually is much, much higher than sustain talk, and the exact opposite is true for behaviors that were not consistent with motivational interviewing. Now in this particular study, change talk never emerged after motivational interviewing inconsistent behaviors. So the model we're trying to build here is that motivation inconsistent behaviors are more likely to evoke change talk, which is predictive of more change. And the opposite is true for motivational interviewing inconsistent behaviors, which is more likely to evoke sustain talk, and that's less likely to cause change. The key thing about this model that we're building here is that you have full control over how you behave, and what you can influence and evoking during that encounter. You actually don't have a lot of control over this part, which is the actual implementation of that motivation and desire to change, into actual change. As I alluded to earlier, patients have to do that themselves. They have to actually go to treatment, take the medication, not use opioids, and do other things, they're in full control. So one of the sayings in motivational interviewing is we should take full control or full responsibility of the intervention itself but not the outcome, because we can't. We have some responsibility of course, but ultimately patients themselves have to actually do the change. How do we actually evoke change talk? One of the first things we teach is actually what's called the taste of MI questions. And this aligns with the first four DARN-CAT, desire, ability, reason, need. So questions like, "What do you want to change?" If you were to stop using heroin, how would you go about doing it, or how would you be successful? If you want to stop using heroin, what are the three most important reasons for doing so? Or on a scale of one to 10, 10 being completely important, one being not all important, how important is it for you to stop using heroin? This last one in particular, actually, it's not the number that we're after, it's actually the follow up question. Okay, so you picked a five, well why'd you pick a five and not a lower number? What I want you to notice is that the answers to these questions are always change talk. And this is what we mean by not arguing for change but evoking change talk from patients themselves. And so, when we do these quick sort of trainings, we recommend the clinician to, in clinic this afternoon, why don't you try asking some of these questions? One of the, there are many variations to all these, one of the other variations will be something like, if in the next couple months is there a particular thing you want to do to improve your health? For example, so again, there are many ways to ask these questions, but the goal again is to not argue for change ourselves, but to evoke change from the patient themselves. And there are many other questions you can ask, and when we do the full training which lasts a little bit longer than this, we have a long list of different questions you can ask to evoke change talk. Here's some quick examples. Looking ahead, alluding to how patients want their lives to be different in the future, how would you like your life to be different in a year from now? Makes them think, "Yeah, how would I want my life to be different?" In the coming year, what are your top priorities for your health? So this is sort of alluding to the hill that I talked about about earlier, where they would rather be, where they aspire to be, where they dream to be. Many patients come to us for help because they want their lives to be different. So asking about it, how do you want your life to be different? Looking back turns out to be another easy strategy because the majority of our patients have had prior successes, or attempts, or efforts, and it's very easy to evoke that. And prior attempts or steps taken already, count as change talk, the DARN-CAT, the T is steps taken already. So what made you decide to go to AA meetings last year? What supports were the most important? So why did you do that before, that was actually helpful for you? It looks like you're in treatment for over a year back in 2014, how were you so successful? So again, these questions are designed to evoke prior successes, prior efforts, because talking about it on its own can be quite motivating. During the evoking phase, what's really important is that patients will say all kinds of things. So here's an example. "I don't drink any more than my friends. Sure, sometimes I feel a little foggy the next day, but it's no big deal." When you first hear this comment, It's sort of, us as clinicians will immediately cue into the negative aspects, or I don't drink more than my friends, downplaying the severity, it's no big deal, it's not a problem. But what's important here for us as clinicians doing the motivational interviewing is to begin to shift our focus away from the sustain talk, which is what the first and the last comments refer to, but the middle part. Sure I feel a little foggy the next day, this I would argue is change talk. This this is potentially a reason for why this patient may change their behavior. So this is the classic motivational interviewing response, this might be you feel a little foggy the next day, which is a simple reflection that we went over before, and then we're pairing that with a open ended question, tell me more about that. And I'm ignoring the first and the last part because that's how the argument begins, well actually your drinking level is more than your peers and your liver enzymes are elevated, so it is sort of a big deal, that's how the argument begins. Here we're focusing on the change talk, and this is what's needed during the evoking phase is to have the laser sharp focus on strengthening, evoking, validating, affirming, change talk and actually ignoring the sustain talk and letting it roll off, and sometimes we call that rolling with the resistance. Just don't argue with it, just focus on the change talk. Another response might be you're worried about how it's affecting your work. What do you already know about the, how alcohol can affect your brain? And so again, this is reflecting first, and then asking an open ended question. Let's see another example. "It's such a hassle to take my medications. I know I'm supposed to take them, but I don't even have them with me half the time. There are good reasons to be on them, but it's just not possible." Again, as clinicians, when we hear this, it's just a laundry list of excuses and reasons why this person doesn't want to change. But if you actually dissect this utterance, you discover that it's full of change talk. I know I'm supposed to take them, there are good reasons to be on them, and I don't even have them, half the time I do, so suggesting that half the time this person does take or have have the medications with them. So you have good reasons to take them, tell me about that. So that would be sort of an easy one. Other examples might be, "Despite the hassle, you find a way to take them some of the time. How are you successful during those times?" So this is the prior successes, right? So reflect it, demonstrate your listening, and then pairing that with a question, in this case, it's the looking back, well how were you so successful? You know, our tendency would would say, why did you fail half the time? But again, in motivational interviewing our focus shifts, why are you successful during those times? Because we want to know why it worked, and in a way we're asking how can we get more of that? Let's see, one more example. "I don't want any medications. I want to stop using heroin, but I've tried detox five times already. I know buprenorphine can help, but I don't want to get hooked on that. I want to do it my way." Again, it sounds like a bunch of excuses and resistance towards change. But again, if you look at this more carefully, you discover it's full of change talk. I want to stop using heroin, I've tried detox five times, buprenorphine can help, I want to do it. One of the important skills in motivational interviewing, I talked about the importance of reflective listening and et cetera, acknowledging the ambivalence, not arguing for change, but this is another really important skill, is to be able to discern change talk from sustain talk in real time as it's coming at you from the patient. So an example or response to this might be, "You know you should stop using heroin. Tell me more about that." Or, "You've tried many things to stop heroin. What do you already know about buprenorphine?" Or, "What do you think might be most helpful?" So there are many ways you can respond to this, but again, the point is our goal here is to recognize change talk and focusing on that, and not argue with the sustain talk. And this is an idea called snatching change talk out of the jaws of ambivalence because patients don't know that they're giving you change talk and sustain talk in this way. It's our task to try to discern it, separate it, and focus on strengthening one side of the ambivalence. And when you get change talk after all this work that you've done, if you are able to evoke change talk, you want to do something about it, just like I gave you examples, ask for elaboration, affirm it, you can reflect it, again, don't just let it go. And if you ask for more, if you affirm it, and reflect it, you'll actually end up getting more change talk, which is actually exactly what we want to do. So now you've done the engagement, the focusing, the evoking, and finally you get to planning. So at the end of the visit or after several minutes, you need to move on, so you want to engage in some sort of planning. And this is translating this motivation into action if possible. And one skill that I want you to walk away from this, is this idea of a change talk bouquet. And the idea is that during the interview, you're collecting actually important things, the change talk, and we might call them the flowers. And during this transition from the evoking phase to the planning phase, one strategy is to use what's called the change talk bouquet, is to gather all the change talk you heard, and showing it back. What you're doing in a way is to say, "Look at all the pretty reasons why you are telling me why you want to change." And then you're pairing it with what we call a key question. So here's an example. "You're tired of being so strung out on pain meds you spend a fortune on them already, and your wife has threatening to leave you. You've heard good things about buprenorphine and you're willing to try it. So where does that leave you?" So there's a change talk bouquet and a key question combination. Here's another example. "You're beginning to worry that your drinking is actually a little out of control. And the DUI last week was real wake up call. Even before today you've been thinking about doing something about it. Where should we go from here?" One more example. "You've watched too many friends overdose, and you're sick of living like this. You've done well when you're in treatment, and you want to get back to your career and things that are important to you. You're determined to get off heroin. What will you do?" So again, a change talk bouquet and a key question combination. Now it doesn't mean that just because you use this, patients are ready to change. So the key question is a probe, you're getting a sense of where they are on that hill, sometimes they're still at the bottom, sometimes they're way, way up high. Wherever they are, if they're not really willing to change, then the focus should be on agreeing to keep talking about it, we going to continue to demonstrate empathy, to agree to provide ongoing support and accountability, and to repeat this process over. But if they're willing to change, then we recommend some version of a smart plan. And this is when you actually can begin to strategize and talk about how to overcome some of the barriers, and other problems that they're encountering. Smart planning very briefly is to be very specific about the the behavior change, that the change should be measurable, that it should be achievable and realistic, and timely, meaning when are you going to do it? So that's the four processes that I summarized and the engagement, engaging, focusing, evoking, planning. The engaging part is actually very important, it's the relational foundation and motivational interviewing where you demonstrate that we're going to listen, this, I mentioned earlier that the more we're able to respect patient autonomy and not violate it, paradoxically patients are more willing to listen to us, particularly if we're able to demonstrate empathy. Focusing again is the idea that we should align our agendas to make sure that we're talking about the same target behavior. And evoking is where we are strengthening evoking change talk by avoiding arguing with a sustain talk, avoiding arguing for change ourselves, but to evoke this from the patients themselves. And then the planning is when we transition to using the change talk bouquet, the key question combination move. And then if applicable, do some smart planning, or simply agree to keep talking about it in the future. Using this strategy, I do believe that hopefully you'll feel less frustrated having these conversations about behavior change, and potentially be more effective in helping patients change behavior. So practice is important. This is not a knowledge, you don't get better doing this without actually practicing. Ideally, you get some feedback and there are many strategies to do that. And so recording and getting feedback on that from cohorts is one strategy. There are additional trainings like workshops, or courses, or trainer events and there are a variety of them available. And one place to find these, and this information is on the website called motivationalinterview.org. This is the website for the MINT The Motivational Interviewing Network of Trainers website, full information, research papers, videos, DVDs, forums, training events, et cetera. So great, great place to get more information. Here are all the references that I cited today. And here's additional information for the PCSS Mentoring Program, and here's information there, it's freely available. This is a discussion forum, again, if you have a particular clinical question, to ask questions to your colleagues, and these are all the different organizations that are partnering with AAAP to make PCSS available. Thank you very much for your attention.

motivational interviewing

Joji Suzuki

behavior change

opioid use disorders

engagement

reflective listening

internal motivation

training