[0:04]There is an inherent contradiction in substance use that goes like this. I know my use is a problem, I want to stop, but I keep using anyway. We call this ambivalence, and it's present in all of us when facing a decision to make a change. Ambivalence can be particularly confounding, however, when we see the devastating consequence of a patient's substance use. We might ask, how are they not convinced that change is necessary? Targeting that ambivalence, however, to resolve it in the direction of change is a key step on the path to recovery. Motivational interviewing is a style of interacting with patients that addresses ambivalence and enhances the patient's motivation to change. The goal is to avoid creating pushback or what's known as sustain talk, that is, talk that argues for the status quo, for things just to remain the same. We avoid sustain talk by not arguing, shaming, warning, or providing unsolicited advice. Rather, this interview style works with a patient in a calculated manner to increase the moments in which the patient uses their own words to talk themselves into change. This type of talk is known as change talk. When done well, motivational interviewing increases the likelihood that your patient will enter into and remain in treatment. By the end of this lesson, you will understand the five underlying principles of motivational interviewing and be able to apply those principles by using a framework called OARS. Let's jump into the five main principles that embody the spirit of motivational interviewing. The first therapeutic principle is to express empathy through reflective listening. Reflective listening establishes a safe environment, builds trust, and creates an opportunity to examine issues and prompt methods for change. Empathy does not mean that you blindly support anything the patient says. It is a tough line to walk sometimes, being able to show acceptance but not necessarily agreement. Reflective listening demonstrates that you have accurately heard what the patient is feeling, and communicates that the provider understands what the patient has said. So here's an example. The patient says, yeah, I have been using drugs for so long, it is hard to imagine what my life would be like without them. A provider practicing reflective listening might respond with this. When you imagine life without drugs it is hard to picture, but you're starting to wonder what this kind of change might be like. The second principle is to develop discrepancy. We know that motivation for change increases when a patient perceives discrepancies between their current situation and their hopes or goals for the future. This technique allows you to step in and dig deeper to see if there's a conflict between the addiction and the patient's goals, personal values, or spiritual beliefs. Gently highlighting the difference between where they are now and where they want to be, which is generally done through reflective listening, helps nudge patients in the direction of change. Ideally, like in all principles of motivational interviewing, the patient, rather than you as the provider, should present the arguments or provide the reasons for change. An example of developing discrepancy would be a provider saying something like, On one hand, drinking relieves some of your anxiety and helps you feel comfortable in social situations. On the other hand, you are concerned drinking is affecting your sleep and your work performance.
[3:48]In this case, you are acknowledging the benefits, but ending the reflection by noting the downsides. This makes it more likely that the patient will respond to the negatives by saying something like, yeah, that's right. It really bothers me when I can't give my all to work. The third principle is to avoid argument and direct confrontation. If you have any experience in dealing with challenging patients, you've probably at some point or another been drawn into an argument, especially if that patient is unsure or unwilling to change. Trying to convince a patient that a problem exists or that change is needed when they don't see it that way, will increase sustained talk, probably sow discord, and in some cases increase substance use.
[4:39]Arguments with a patient can rapidly fall into a power struggle and undermine motivation for change. So if this happens, take a deep breath, simply recognize it, and use it as a sign that you need to alter your strategy. Instead of arguing, you want to dance with discord, which is the fourth principle. In other words, you want to adjust your patient's sustained talk, rather than opposing it directly. Motivational interviewing, remember, is gentle, like a dance, it's never confrontational. Any talk that is arguing to stay the same is sustain talk, and it might look like minimizing the consequences of use, blaming other people, or making excuses. The simplest way to dance with discord is to simply acknowledge the person's disagreements, feeling, or perception in a neutral way. Take the following example. A patient might say to you, who are you to be giving me advice about drinking when you probably go home and drink, too. You might be tempted to engage that patient by defending yourself. But the motivational interviewing way would be to respond with something like, It's hard to imagine not drinking. The fifth and final principle of motivational interviewing is to support self-efficacy and optimism. It's well known in addiction treatment that patients have typically lost their confidence or their belief that they can maintain even the most minimal change in behavior. Everyone brings something to the table, so recognize the patient's strengths and highlight them when possible. Belief in the prospect of change is an incredible motivator. Not only must patients believe change is possible, but also be responsible for carrying out the change. Educating the patient, maybe by helping them to understand the biology of addiction or the statistics about recovery, can help lessen the shame and guilt they may have and give them hope that there is still a possibility for recovery. So to review, the principles of motivational interviewing hinge on being empathetic, developing discrepancies, avoiding arguments, dancing with discord, and supporting self-efficacy. Now that we reviewed the principles, let's jump into some specific strategies. There are four core motivational interviewing skills, also known by the acronym OARS. OARS stands for open-ended questions, affirmations, reflective listening, and summaries. These techniques can be utilized in any patient conversation, but are particularly useful in early stages of treatment. Let's start with O for open-ended questions. Open-ended questions by definition require more than a yes or no answer. An open-ended question might sound something like this, how would you like things to be different? as opposed to, do you want things to be different? This latter question is a closed-ended question and can be answered with a yes or no. Closed-ended questions stifle conversation and dialogue. Using open-ended questions, however, allows the patient to tell their story as opposed to leading them in a specific direction. The second skill is affirmation. Now these are statements or gestures that strengthen the connection between you and your patient. I love affirmations. They make everyone feel good. But affirmations must be sincere to work. So identify your patient's strengths and abilities to promote success and prevent discouragement. Affirmations will build the patient's confidence in their ability to change. Here are some examples of affirming responses. I know it wasn't easy for you to get here, but you made it. That shows a lot of commitment to your health. Or, that was really tough, but you made it through. You're resilient. The next strategy is R for reflective listening. While this may appear easy, you'd be surprised how hard it is to do. At first, it might not feel natural. You must have both a genuine interest in what the patient has to say, and a desire to understand how they see things. In other words, you must develop empathy. Good reflections might be to simply repeat what the patient says, rephrase or paraphrase what they said, or to offer a deeper reflection of feeling. Reflecting a feeling might sound like, you feel stuck. Or, you're really angry about this. And remember that it's totally okay to get your reflection wrong. Patients don't get mad. Instead, they'll correct you. For example, no, I don't feel angry. I feel misunderstood. And now you as the provider have moved forward in understanding your patient's perspective. The final strategy in OARS is S for summaries. Again, just like in any standard medical interview, it's essential to summarize throughout the conversation. Here, it can be particularly helpful at transition points, for example, after they have talked about specific experiences or near the end of your conversation. Here are some useful structures of summary statements. Let me see if I understand so far. Or, here is what I've heard, let me know if I missed something. With this technique, it's important to give special attention to change statements made by the patient. And above all, be concise in your summary. So there you have OARS, open-ended questions, affirmations, reflections, and summaries. There have been countless studies on the effectiveness of motivational interviewing, and we hope that you and your patients benefit from adopting this communication style.
