© Alcohol Medical Scholars Program1 Motivational Interviewing Regarding Substance Use in the...

© Alcohol Medical Scholars Program 1

Motivational Interviewing

Regarding Substance Use in the

Medical Setting

John M. Wryobeck, Ph.D


SUD in the Medical Setting

• ~ 30 % ED Pts have AUD

• 50% trauma Pts, + for drugs

• 24% hospital admits have AUD

• 33% non-trauma admits related to AUD


SUD in the Medical Setting

• ~ 20% medical clinic Pts have AUD

• SUD among top 3 diseases worldwide

• SUD related to many injuries/disease


SUD Interventions

• External motivation

• Education – information motivates change

• Persuasion – logic motivates change

• Elicit internal motivation

• Explore Pts knowledge/thoughts about change


This Lecture Reviews

• Definition & Principles

• Basic Skills of MI

• Basic Steps of MI

• Research supporting MI


Definition & Principles

• Directing style• 1 active participant

– Manage

– Lead

– Take charge

– Go along

• Guiding style • 2 active participants

– Enlighten

– Encourage

– Support

– Elicit


Principles - Ambivalence

• Ambivalence is normal

• Persuasion & confrontation avoided

• Elicit/reinforce own motivation

• Discuss how change relates to desires


Principles - Empathy

• Express empathy Understanding & honesty

• Communicates acceptance, support

• Non-verbal & “reflective” empathy

• State emotion underlying Pt statement

• Paraphrase Pt statement to show understanding


Example: Empathy

• Pt: I say I am going to quit but don’t.

• Dr: It is frustrating not accomplishing what you want.

• Pt: Drinking is ruining my health but I can’t change.

• Dr: ?


Principles – Roll w/ Resistance

• Resistance when Pt feels unheard

• Ambivalence & self determination ≠ resistance

Resistance through reflective listening

• Requires “active listening”

• Invites Pt to view situation differently


Example: Reflective Listening

• Pt: What do you know about drinking?

• Dr: It’s hard to imagine I could understand.

• Pt: My drinking really isn’t that bad.

• Dr: ?


Principles – Confidence

• Develop confidence

• Pt must believe they can change

• Support small changes

• Any + change Pt willing to make is supported

• Elicit/reinforce statements of confidence

• Use reflection, evocative questions


Principles - Confidence

• Evocative questions• What might be a good first step?• What gives you confidence that you might do

this?

• Past success• What change have you made successfully

and what did you learn in making that change?

• When you last abstained, what worked for you?








Basic Skills - Asking

• Asking

• Open-ended questions gain more information

• Skillful asking is element of guiding style

• What kind of change makes sense to you? vs• Are you willing to make any changes?

• Open-ended questions are simple, focused, neutral


Example: Asking

• Learning questions

• What went well and why?

• What would you do differently now?

• How might the outcome be improved?

• Other?


Example: Asking

• Value Questions

• What are your priorities at this time in life?

• What matters to you?

• How does alcohol fit in your life?

• Other?


Example: Asking

• Skill Questions

• What did you learn about your skills as you cut back on your drinking?

• Were there any surprises?

• What are you doing (behavior) when you find abstinence/reduction is going well?

• Other ?


Basic Skills - Listening

• Listening• Reflect resistance• Reflect change-talk

Desire

Ability

Reasons

Resistance

Status Quo


Basic Skills - Informing

• Informing

• Information exchange vs receptacle

• Provide choice

• Inform skillfully

• Elicit-inform-elicit








Steps - Rapport

• Establish rapport

• Ask permission

• Non-threatening language


Steps - Rapport

I would like to spend a few minutes

talking about how alcohol fits into

your life. Would that be ok?


Steps - Scaling

• Assess Pt motivation• Importance Ruler• Confidence Ruler

1 2 3 4 5 7 8 9 106

Change Talk Resistance


Is important & I can change.

Is important but I cannot change.

Not important but I could change.

Not important & I cannot change.

↑ Importance

↓ Importance

↑ Confidence ↓ Confidence


Case Example - Scaling

• Dr: How important is it to make changes to your drinking?

• Dr: How confident are you that you would be successful if you tried to quit?


Steps – Reflect Change talk

• Elicit Motivation

• When you hear change talk:

• Reflect it

• Use open-ended question to elicit more


Case Example

• Pt: I sometimes drink too much.

• Dr: What makes you think that?

• Pt: I don’t know when to quit.

• Dr: You don’t feel you need to stop but drinking causes you problems.


Steps – Resolve Ambivalence

• Resolve ambivalence = identify inconsistency

• Inconsistency between values & behaviors

• Discussion of pros and cons of change

• Identify for what Pt is motivated


Case Example

• Pt: I need to cut down but I entertain clients.

• Dr: Client’s take precedence over your health.

• Pt: No, my health is important to me.

• Dr: You can entertain clients and be healthy by altering drinking.








75 77

25 23

0

10

20

30

40

50

60

70

80

Alcohol Diabetes, Asthma,Weight

% of RCT’s Finding MI Effective in Medical Settings


52

82

76

30

60

35

0

20

40

60

80

100

PrescriptionDrugs

# Drinks WeekMedical Setting

# Drinks WeekSUD Setting

% Reduction in Use Medical/SUD Setting


22

50 32

1121 18

0

10

20

30

40

50

DUI Arrest Alc Related Injury Excessive Drinking

% Occurrence, Emergency Dept Setting

3 Years

6 Months


Summary

• AUD’s will be seen in medical settings

• Guiding as alternative to directing

• Understand Pt ambivalence

• MI principles/skills/steps support Pt

• Research supports use in medical settings

Date post:	14-Dec-2015
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